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THE LIBRARY
OF
THE UNIVERSITY
OF CALIFORNIA
PRESENTED BY
PROF. CHARLES A. KOFOID AND
MRS. PRUDENCE W. KOFOID
A*S5^^^^^^0
^■-..*Si-i Y^'\^i^^>^.
-*^^l>*iiV^ V V\
^^^
1
NEW ELEMENTS
OPERATIVE SURGERY;
WITH
An Atlas of neajrly Three Huxidred engravixigs,
BEPBESENTING
THE PRINCIPAL OPERATIVE PROCESSES, AND A GREAT NUMBER OF SURGICAL-
INSTRUMENTS.
By ALF. a. L. M. VELPEAU.
Surgeon to the Hospital of la Pitie ; Fellow of the Faculty of Medicine of Paris;
Surgeon to the Dispensaries of the Philanthropic Society ; Professor of Midwifery, Anatomy, Pathologicu^l
and Operative Surgery ; Member of the Medical Society of Emulation of Paris ; Corresponding
Member of the Medical Societies of Tours, Louvian, &c. &c.
friTH AN APPENDIX OF NOTES,
By GRANVILLE SHARP PATTISON, M. D.
Professor of Anatomy in Jefferson Med. Col. Phila.
?!2^asi)ingtoit :
PUBLISHED BY DUFF GREEN.
1835.
INDEX.
Preface.
Introdtjctio^-.
Elementary Operations.
Chapter I. — Divisions
Section I. — Cutting instruments
Article 1. Manner of holding the bis-
toury . _ - -
§ 1. First position. Bistoury held as
a knife, the edge downwards
§2. Second position. Bistoury held
as a knife, the edge upwards
§3. Third position. Bistoury held
as a pen, the edge downwards,
the point forwards
§4. Fourth position. Bistoury held
as a pen, the point backwards
§ 5. Fifth position. Bistoury held
as a pen, the edge upwards
§ 6. Sixth position. Bistoury held
as a drill-bow _ . .
Art. 2.-JHanner of holding the scis-
sors - - - -
Sect II. — Different kinds of incisions
Art. 1. Simple Incisions
§ 1. Incision from without inwards
§ 2. Incision fr-om within outwards
§ 3. Upon a director
§ 4. With a fold of the integuments
4 5. Horizontally - - -
Art. 2. Compound incisions
§ 1. The V incision
^ 2, The oval incision
§ 3. The cross incision
§ 4. The T incision
§ 5. The elliptical incision
§ 6. The crescentic incision
Art. 3. Incisions applied to abscesses,
to collections of fluids
§ 1. Incision from within outwards
4 2. Incision from without inwards
§ 3. Complex incisions
Art. 4. Incisions applied to the dis-
section of tumors and of subcuta-
neous cysts - . >
Page
III
IX
1
1
1
1
2
o
13
§1. Form of the incision -
1. Straight incision
2. V incision . - -
3. Crucial incision
§ 2. Dissection of the Flaps
1. Concrete tumors
2. Cancers . . _
3. Cysts
Art 5. To cause the least possible
pain - - - -
Sect. III. — Punctures
Chapter II. — Reunion
Art. 1. Suture ...
§ 1 . Interrupted suture
§ 2. The suture of Le Dran
§ 3. Furrier's suture
§ 4. Zigzag suture
§ 5. Twisted suture
§ 6. Quilled suture
CoKPLKX Operations.
Title I. — Operations upon the Blood-
vessels J - . .
Chapter I. — Operation for aneurism
in general - - - .
Sect. I. — Anatomical remarks
Sect. II. — Spontaneous cvu'e
Sect. III. — Curative methods
Art. 1. Method of Valsalva -
Art. 2. Refrigerants and styptics
Art. 3. Compression
§ 1. Mediate compression -
§ 2. Immediate compression
Art. 4. Cautery
Art. 5, Ligature - . .
§ 1. Nature and form of the ligature
§ 2. Permanent ligature -
§ 3. Precautionary ligatures
§ 4. Temporary ligature -
Operative processes - - -
§ 5. Two ligatures with immediate
division of the artery
§ 6. Ligature throiigli the artery -
§ 7. Mediate ligature
§ 8. Immediate ligature
iii
'<.'-'
i:36Q>acr
IV
INDEX.
Page
Art. 6. Methods of operation - 48
Relative value of the three princi-
pal methods - - - 52
Art 7. Maiiual - - -55
§ 1. Old method - - -55
§2. Method of Anel - - 56
§3. Results of the operation - 60
Art. 8, Of the suture - - 62
Art. 9. Torsion, Bruising - - 62
Art. 10. Acupuncture - - 63
Art. 10 {again). Changes occurring
in vessels of a limb after the opera-
tion for aneurism - - -65
Chapter II. — Operations for the parti-
cular aneurisms - - 67
Sect. I. — Operations for diseases of
the arteries of the inferior extre-
mity - - - -67
A. Anterior tibial in the foot - 67
Art. 1. Anatomical remarks - 67
Art. 2. Surgical remarks - - 68
Art. 3. Manual - - - 68
B. Anterior tibial in the leg - 69
Art. 1. Anatomical remarks - 69
Art. 2. Surgical remarks - - 69
Art. 3. Manual . - - 70
C. Posterior tibial - - 71
Art. 1. Anatomical remarks - 71
Art. 2. Surgical remarks - - 72
Art. 3. Manual - - - 7o
D. Peroneal - - - 74
E. Popliteal - - -75
Art. 1. Anatomical remarks - 75
Art. 2. Surgical and historical re-
marks - - - -75
Art 3. Manual - - - 78
Result of the operation - - 78
F. Femoral - - - 79
Art. 1. Anatomical remarks - 79
Art. 2. Surgical and historical re-
marks - - - - 80
Art. 3. Manual - - - 83
§ 1. Inferior half - - - 83
§ 2. Superior half - - - 84
4 3. Results of the operation - 84
G. Ligature of the circumflexes or
of the profunda - - 85
H. External iliac - - - 85
Art. 1. Anatomical remarks - 85
Art. 2. Historical and surgical re-
marks - - - - 86
Art. 3. Manual - - - 88
L Internal iliac - - - 91
Art. 1 . Anatomical remarks - 91
Art. 2. Surgical and historical re-
marks - - - - 91
Art. 3. Manual - - - 92
K. Primitive iliac - - - 93
Art. 1. Anatomical remarks - 93
Art. 2. Surgical and historical re-
marks - - - - 93
Art. 3. Manual ...
L. Abdominal aorta
Art. 1. Anatomical remarks
Art 2. Surgical and historical re-
marks - . . .
Art. 3. Manual ...
Sect. II. — Arteries of the superior ex-
tremity - . - ,
A. Arteries of the hand -
Art. 1. Anatomical remarks
Art. 2. Surgical remarks
Art. 3, Manual ...
B. Arteries of the fore-arm
Art. 1. Anatomical remarks
Art. 2. Surgical and historical re-
marks . - - .
Art. 3. Manual ...
C. Artery of the elbow
Art. 1. Anatomical remarks
Art. 2. Surgical and historical re-
marks _ . _ _
Art. 3. Manual . . _
D. Brachial ...
Art. 1. Anatomical remarks
Ai't. 2. Surgical and historical re-
marks - - . -
Art. 3. Manual - . -
E. Axillary - . _
Art. 1. Anatomical remarks
Art. 2. Surgical and historical re-
marks - - . _
Art. 3. Manual ...
F. Subclavian . . ,
Art, 1. Anatomical remarks
Art. 2. Surgical remarks
Art. 3. Manual
Sect. III. — Arteries of the head
A. Temporal - - -
B. Facial - - -
Sect IV. — Arteries of the neck
A. Primitive carotid
Art. 1. Anatomical remarks
Art. 2. Surgical and historical re-
marks . . - -
Art. 3. Manual - - -
B. Internal and external carotids
C. Facial . - - -
D. Thyroids
E. Innominata _ - -
Art. 1. Anatomical remarks
Art. 2. Surgical and liistorical re-
marks _ . - -
Art. 3. Modes of operation -
Chap. III. — Naevi Materni, Erectile
Tumors - - - -
Chap. IV.— -Varix
Title II. — Of Amputations
Chap. I. — Amputations in general
Sect. I. — Indications
Art. 1. Gangrene - - -
Art 2. Fractures - - -
Page
94
95
95
95
97
98
98
98
98
98
99
99
100
100
101
101
102
104
105
105
105
106
106
106
107
108
110
110
112
113
116
117
117
117
117
117
118
120
122
122
123
123
123
124
125
127
129
133
133
135
135
136
INDEX.
Art. 3. Luxations
Page
136
A. Flap method
.
203
Art. 4. Caries, Necrosis
137
B. Circular method
-
204
Art. 5. Cancerous affections
137
Art. 6. Arm
-
205
Art. 6. Aneurism
138
A. Circular method
-
206
Art. 7- Suppuration - - .
138
B. Flap method
-
20?
Art. 8. White swelling
139
Art. 7. The arm at the joint
-
Art. 9. Tetanus— Bite of a rabid ani-
§1. Manual -
-
208
mal - - - - .
139
A. Circular method -
-
208
Art. 10. Amputations of convenience
140
B. Flap method
-
209
Art. 11. Gunshot-wounds
141
C. Oval method
-
213
Sect. II. — Preliminary attentions
143
§2. Comparisonof the methods -
214
Art. 1. Counter-indications
143
Art, 8. The shoulder — ^Jiistory and
Art. 2. Time for the operation
144
indication
-
215
Art. 3. Point of amputation
147
Manual
-
215
Art. 4. Preparatives - - -
147
Sect. II. — The inferior extremity
215
Sect. Ill, — Methods of operation
150
Art. 1. Toes
215
A. Amputations in continuity
150
Art. 2. Metatarsus
216
Art. 1. Circular method
150
§ 1. In the continuity
216
§ 1, Manual - - - -
150
A. First metatai-sal bone
216
§2. Dressing - - - -
162
B. Second metatarsal bone
217
§ 3. Consecutive treatment
167
C. Extraction
218
§ 4. Accidents - - -
169
D. Collectively
218
Art. 2. Flap method -
175
§ 2. Disarticulation -
218
Art. 3. Oval method
176
Manual
219
B. Amputation in the contiguity
177
Art. 3. Amputation of a part
of the
Chap. II.— Amputations in particular
179
tarsus
-
224
Sect. 1.— The upper extremity
179
Art. 4. Comparison of the two par-
Art. 1. The fingers
180
tial amputations of the foot
-
227
§ 1. Partial amputation
181
Art. 5. Extraction of a part
of the
Manual . . . -
181
tarsus
-
227
Dressing and after treatment
183
Art 6. The whole foot
.
227
§ 2, Amputation of the whole finger
183
Art. 7. Amputation of the leg
-
228
Manual - - - -
184
Manual
-
230
§ 3. Amputation of the fingers col-
1. Process of Sabatier
-
233
lectively - - - -
186
2. « of Dr. Physic
.
233
Art. 2. Metacarpus - - -
387
3. " ofBaudenorB.
Bell .
233
§ 1. In the continuity
187
Dressing
-
233
Amputation of the metacarpus in
Flap operation
-
234
a body - - - -
188
1 . Process of Verduin
-
234
Amputation of a single bone
188
2. " of Hey -
-
234
§ 2. In the contiguity
189
3. " of Ravaton
.
234
A. Metacarpal of the thumb — Am-
4. " of y ermale
-
235
putation - - - -
189
5. " ofDupuytren
-
235
Extraction
191
6. « ofRoux -
.
235
B. Fifth metacarpal — Amputation
192
7. « of the Author
-
235
Extraction - ^ -
192
In the articulation -
-
236
C. Middle metacarpal — Amputa-
[Manual
-
239
tion - - - - -
193
1. Process of Hoin
239
Extraction - - -
194
2. « ofLeveille
239
E. Disarticulation of several or of
3. « ofBlandin
239
all the metacarpal bones collec-
4. « of Smith
240
tively - - - -
194
5. « of Rossi
240
1. Anatomical remarks
194
Dressing
240
2. Manual - - - .
195
Art. 9. The thigh
241
Art. 3. The wrist
196
§ 1. In the continuity
241
A. Circular method
197
Anatomical remarks
241
B. Flap method
198
Manual -
242
Art. 4. The forearm -
199
Circular method
242
A. Circidar method -
200
Position of assistants
242
B. Flap method - w -
201
Flap operation -
243
Art. 5. The elbow
203
1. Process of Vermale
244
INDEX.
2. Process of Langcnbeck
In the contig-aity
History and value
Anatomical I'cmarks
§ 1. Manual — Circular method
Eng"lish process -
Flap operation -
1. Process of Labonette -
2. « of Blandate
3. "of Manee
4. « of Ashmead
5. « of Delpech
6. " of M. Larry
7. " of Blandin
8. « of Lisfranc
9. " of Dupuytren -
10. «« of Beclard
11. « of Guthrie
C. Oval operation
1. Process of M. Cornuar -
2. « ofLecoIletan -
§ 2. Relative value of various me-
tliods . . - .
Title III. — Excision of the Bones
Chapter I. — In the continuity
1. Recent fractures
2. Wounds from fire-arms -
3. Old non-consolidated fractures
Method of operating
Org-anic lesions -
\rt. 1. The ribs
Operation
Art. 2. The sternum
Art. 3. Lower inferior jaw
History and value
Operation
After operation -
Art. 4. Superior maxillary bone
('hapt. II. — Excision of the joints
Sect. I. — Thoracic members
Art. 1. The hand -
Operation
Art. 2. The wrist -
1. Operation. First method
2. M. Dubled's method -
3. Moreau and Roux's method
Art. 3. The elbow -
1. Operation. Park's method
2. Moreau's method
3. Dupuytren's method
4. Author's method
Art. 4. Radius
Art. 5. The shoulder
Operation. (1st White's) method
2. Moreau's methods
Mancas's "
Sabatier's
Bent's
Morel's
Lyme's
Remarks
Page
244
245
245
247
248
248
248
249
249
249
249
250
250
250
251
251
251
251
251
252
252
252
254
254
254
255
255
255
256
257
257
257
258
258
259
262
262
265
267
267
267
267
267
268
268
269
269
269
269
270
271
272
272
273
273
273
273
273
273
273
Art. 6. The clavicle - - - 275
1. Acromial extremity - - 275
Extirpation - - - 276
Sect. II. — Abdominal members - 277
Art. 1. Tibio-torsal articulation - 278
Operation. 1. Moreau's method - 278
2. Roux's method - - - 278
Value - - . - 278
Art. 2. Knee - - - 279
Operation. 1. Park's method - 279
2. Moreau's method - - 279
3. MM. Sanson and Begin's method 280
4. Lyme's method - - 280
Remarks - . . 280
Art. 3. Head of the femur - - 281
Artificial articulation - - 281
Title IV. — Trepanning - - 282
Chapt. L — The cranium - - 282
Parts that admit of it - - 284
Apparatus, operation, and 1st step 285
2d step - - - - 286
3d step and remarks - - 287
Dressing - - - 288
Chapt. II. — Thorax, pelvis, and extre-
mities - - - . 290
Scapula, spine, and long bones - 292
Special Operations - - . 293
Operations on the head - - 293
Chapt. I. — The cranium - - 293
Method of operating - - 293
Osseous tumors .. - . 294
Encephalocele ... 294
Lupia .... 294
Operation - - - 294
Hydrocephalus - - - 295
Chapt. II.— The face - - 295
Sect. II. — The nose - - . 295
Taleacotian operation - - 295
1. Tagliacozzi's method - - 297
h. M. GrsePs « - - 297
2. Indian - - 298
a. By means of cutaneous flap
from the rump - - 298
h. By transplantation - - 298
c. With the skin of the forehead- 299
3. French method - . 300
Relative value - - - 300
Art. 2. Other operations on the nose 301
Excision of tumors - - . 391
New operations ... 302
Occlusion of nosti'ils - - 302
Rhinoraphia - - - 302
Appabatus of Vision - - 303
Art. 1. Lachrymal passages - - 303
§ 1. Anatomical remarks - - 303
§ 2. Obstruction, tumor - - 304
Anel's method - - - 305
Injections - - - 305
Catheterism - - - 305
Laforest's method - - 305
§ 3. Fistula - - - 306
INDEX.
Vll
Page
Page
Dilatation of the natural passages
307
Orbital cavity
.
.
329
Mej can's method
-
-
307
Art. 4. Globe of the eye
-
-
331
Pallucce's «
-
-
307
§ 1. Foreign bodies
-
-
331
Caboni's *'
.
308
§ 2. Pterygium
-
-
331
Guerin's «
.
.
308
§ 3. Cataract
-
.
332
Care's «
-
-
308
1. History
-
-
332
Dilatation through an
'iccidental
2. Conditions
-
-
332
opening
-
-
309
3. Ages -
-
-
334
Monro's method -
.
-
309
4. Simple or double
-
-
334
Ponteau's «*
.
-
309
5. Preparations
-
-
336
Lecat's «
.
.
309
6. Seasons
-
_
336
Desault's «
-
-
310
Methods of operating
-
-
337
B oyer's modification
-
-
310
Depression
-
-
337
Pamard's method
-
-
310
1. Preliminary attentions
-
•
337
Jurine's "
-
-
310
Apparatus — Instruments
-
337
Foumier's "
-
-
311
2. Operation
-
-
338
Jourdan's "
.
.
311
Ordinary method
.
.
338
Scarpa's «
-
.
311
Process of Petit and Ferrein
.
341
Ware's «
.
-
312
« the author's
.
-
342
Permanent canula
-
-
312
Hyalonyxis
-
-
342
Cautery -
-
.
314
Scleroticotomy -
-
-
34:^
Superior operation
-
-
315
Retroversion or reclinat
ion
-
343
Process of Harveng
-
-
315
Cutting or breaking up
3f the lens
343
Process of Deslande
.
_
315
The lens passed to the anterior
Inferior operation -
.
.
315
chamber
.
.
344
Process of Bermond
-
-
315
Ceratonyxis
.
.
344.
Process of Gensoul
-
-
315
Simple puncture of the
cornea
.
346
FonMATION OF A NEW CANAL
.
.
316
In children
-
.
346
Process of Woolhouse
-
-
317
Consecutive treatment
-
_
347
« of St. Yves
-
»
317
Extraction
-
.
348
« of Dionis
-
-
317
Operation
-
-
349
« of Monro
-
-
317
1. Scleroticotomy
-
-
350
« of Hunter
-
..
317
2, Ceratotomy
_
-
350
« of Scarpa
-
-
318
Inferior keratotomy
-
-
351
« of Nicod
-
-
318
First second and third step
_
352
« of Picot
.
_
318
Process of Guerin and Dumont
_
357
Art. 2. Eyelids
-
-
320
Superior keratotomy
-
-
357
§ 1. Ectropion
-
.
320
Dressing
-
-
358
Process of Antylus
-
-
321
Comparative examination of the
« of Walther
.
.
322
two methods
.
.
359
« of Key
-
-
322
§ 4. Artificial pupil
-
_
363
Blepharoplastic operation
.
322
Methods of operating
-
_
363
§ 2. Trichiasis, Entropion
and Ble-
1. Coretomia or the method by
n-
pharoptosis
-
-
323
cision
.
.
364
Excision
- ■
-
323
Process of Cheselden
_
.
364
Extraction and cauterization
of
« of Sharp
_
_
364
the cilia
.
.
323
« of Odhelius
.
_
364
Eversion of eyehds
.
-
324
« ofjanin
.
.
364
Excision of the edge of the palpe-
" of Guerin
_
_
365
bral - .
-
.
325
" of Maunoir
.
_
365
Crampton's method
-
-
325
" of Adams
.
_
366
Guthrie's «
-
.
325
" of Author
_
.
366
Saunder's «
.
.
325
2. Coredialysis
.
.
367
Vacca-Berlinghieri's method
.
325
Process of Scarpa
.
_
367
§ 3. Tumors
.
.
326
" of Couleon
-
-
367
First process
.
-
326
" of Assalini
-
.
367
Second process
.
-
327
" of Langenbeck
.
S67
Modified cauterization
-
.
327
" of Reisinger
,
-
367
Cancerous tumors
.
_
327
" of Lusardi
.
_
368
4 4. Anchyloblepharon and symble-
" of Donegana
-
-
368
pharon
-
-
328
3. Corectomia
-
-
369
Vlll
INDEX.
Tage
Process of Demours
. 369
Process of Couleon and Gibson
. 369
"* of Beer
• 369
«* ofWalther
369
" of Dr. Physic
370
Relative value of the various me-
thods . - . -
370
§ 5. Puncture — ^incision
372
1. Onyx - . - -
372
2. Hydrophthalmia
372
Operation . . .
373
3. Hypopyon - - .
374
4. Empyesis . - .
374
§ 6. Recision
575
Operation _ - .
375
§ 7. Extirpation -
376
Operation. 1. Process of Bartisch
377
2. Process of F.deHilden
377
3. « ofHeistei- -
378
4. " of Louis
378
First stage
378
Second stage
378
. Third stage and dressing
379
Remarks
380
Artificial eyes
380
Sect. III.— Mouth
381
Art. 1. The lips
381
§ 1. Harelip
381
Cheiloraphy
382
A. Simple harelip
382
a. History ...
382
b. Operative process
385
c. Remarks - . .
387
B. Complicated hai-elip
390
C. Age proper for the operation
391
§2. Excision of the lip
393
4 3: Eversion. Mucous enlarge-
ments - . - .
394
§ 4. Hypertrophy
395
§ 5. Chciloplasm -
396
Manual - - - .
396
1. Ancient process
396
2. Process of Chopart
397
3. « of M. Roux of St. Max-
imin ....
397
4. Process of Professor Roux
398
5. M. Lisfranc's modification
399
§ 6. Genoplasm
400
1. Indian method -
400
2. French «...
401
a. Process of M. Roux, of St.
Maximin ...
401
b. Process of M. Gensoul
401
c. " of Professor Roux
401
§ 7. Abnormal coarctation
402
Art. 2. Salivary apparatus -
404
§ 1. Fistulae
404
A. Of the parotid gland or its ex-
cretory ducts
404
B. Of the duct of steno
405
C. Of the submaxillary gland
409
Page
§ 2. Ranula or frog^s tongue . 410
§ 3. Salivary tumors foreign to the
excretory canal . . 413
Art. 3. The tongue - - - 414
§ 1. Filet - . - 414
§ 2, Aiichyloglossis - - 416
§ 3. Excision ... 417
Art. 4. Isthmus of tlie fauces . 420
§ 1. Excision of the whole or a part
of the tonsils ... 420
§ 2. Abscess — Incision of the tonsils 425
§3. Excision of the Uvula - 425
§4. Staphyloraphy - - 427
A. History - . - 428
B. Manual . . - 431
C. Modifications - - - 433
Sect. IV. — Olfactory apparatus - 434
Art. 1. Nasal fossa - - . 434
§ 1. Hemorrhage — plugging . 434
§ 2. Polypi . - - 435
a. First process of Levret - 441
b. Second « « - 441
c. Brasdor's process - - 441
d. Desault's « - 442
e. Process of M. Boyer - 443
/. « of M.Dubois - 443
g. « of M. Rigaud - 443
h. " of M. Felix Hatin - 444
Art. 2. Maxillary sinus - - 445
§ 1. Perforation - - - 445
§ 2. Foreign bodies — polypi - 448
§3. Frontal sinus — perforation - 450
Sect, v.— The face - - 450
Art. 1. Osseous cysts - - 450
Art. 2. Section of the facial nerves - 451
Sect. Vl. — Auditory apparatus - 455
Art. 1. External ear - - 455
§ 1. Otoraphy - - - 455
§ 2. Otoplasmus - - - 455
§ 3. Perforation. Dilation of the
auditory canal ... 456
§ 4. Foreign bodies - - 457
§ 5. Polypi - - - 459
Art. 2. Internal ear - - - 461
§ L Perforation of the membrana
tympani ... 461
§ 2. Perforation of the mastoid cells 462
§ 3. Catheterism of the Eustacliian
tube .... 464
Title IL— Operations on the Trunk - 467
Chap. I.— The neck - - 467
Sect. I. — Lateral and superior regions 467
Art. 1. Parotid gland - - 467
Art. 2. Submaxillary gland - - 473
Sect. II. — Anterior region - - 474
Art. 1. Thyroid body - - 474
Art. 2. Air passages - - 479
§ 1. Bronchotomy - - 479
A. Surgical and anatomical remarks 484
1. Tracheotomy - - - 489
2. Thyroid laryngotomy - - 490
INDEX.
IX
Page
3. Laryngo tracheotomy - - 490
4. Thyro-hyoid laryng-otomy - 490
§ 2. Bronchoplasmus - - 491
§3. Catheterism - - - 491
Art. 3. Alimentary passages - 491
§ 1. Catheterism - - - 491
§ 2. Foreign bodies - - 494
Chap. II.— The chest - - 499
Sect. I.— Tumors - - - 499
Art. 1. Extirpation of the mamma - 499
Art. 2. Extirpation of tumors in the
axilla - - - - 505
Sect. I[.— Effusions - - 506
Art. 1. Empliysema - - 506
Art. 2. Wound of the intercostal ar-
tery - - - - 513
Art. 3. Paracentesis of the pericardium 515
Chap. III.—Abdomen - - 518
Sect. I. — Effusions and cysts - 518
Art. 1. Paracentesis - - 518
Art 2. Humoral tumors of the liver 526
Art. 3. Cysts and tumors in the inte-
rior of the abdomen - - 527
Sect. II.— Hernia - - - 530
A. Hernias in general - - 530
Art. 1. Radical cure - - 530
§ 1. Topical applications, compres-
sion, position - - - 530
^ 2. Various operations - - 531
§ 3. Possibility of obtaining a per-
manent cure, and whether it ought
to be attempted - - 536
§ 4. Inguinal hernia - . 538
Art. 2. Strangulated hernia - 539
§ 1. Anatomical remarks - *541
a. Sac - - - - 541
b. Aponeuroses - - 544
c. Herniary openings - - 544
§2. Seat of strangulation - 545
Internal Strangulation - - 549
§ 3. Indications . - - 550
§ 4. Herniotomy or celotomy - 561
A. Enterocele - - - 561
B. Epiplocele - - -575
C. Dressings . - - 579
D. Treatment - - - 581
§ 5. Gastrotomy - - - 583
§ 6. Hernia with gangrene - 585
§ 7. Enteroraphy - - 588
Suture on a foreign body - 589
Suture witli invagination - 591
Raybard's process - - 591
Suture with contact of serous sur-
faces - - - 592
Process of M. Jobert - - 592
'* of M. Denaus - - 592
« of M. Lembert - - 593
Ulceration - _ . 594
§ 8. Preternatural anus - . 596
A. Suture - - - 596
B. Compression - - - 597
B
Page
C. Enterotomy or the process of M.
Dupuytren - - _ 595
Sect. II. — Particular hernias - 603
Art. 1 . Inguinal hernia - - 603
§ 1. Anatomical remarks - 603
§ 2. Surgical remarks - - 607
Infantile hernia - - 609
§ 3. Composition - - 611
§ 4. Operation - - 613
Art. 2. Crural hernia - - 618
§ 1. Anatomical remarks - 618
§ 2. Operation - - 622
Art. 3. Umbilical hernia - - 626
§ 1. Anatomical remarks - 626
§ 2. Operation - - 628
Art. 4. Ventral hernias - - 631
Chap. IV. — The sexual organs - 633
Sect. I. — The sexual organs of fie
male - - . - 633
Art. 1. Scrotum - - - 633
§ 1. Anatomical remarks - 633
§ 2. Hydrocele - - 635
Operation - - . 636
§ 3. Ectomia scroti - - 648
§ 4. Castration - - - 651
Method of Maunoir - - 652
« ofZeller - - 657
Art. 2. Copulative organ - - 659
§ 1. Phymosis - - 659
§ 2. Paraphymosis - - 662
§ 3. Strangulation of the penis - 664
i 4. Sectio freni - - 664
§ 5. Adhesions of the prepuce to
the glans _ , - 665
§ 6. Destruction of the prepuce 665
§ 7. Amputation of the penis - 666
Sect. II. — The sexual organs of the
female - - _ 669
Art. 1. Imperforation of the vulva - 669
Art. 2. Puncture of the uterus - 671
Art. 3. Inverslo uteri vaginse - 673
Art. 4. Reduction of the uteinis and
vagina - - - 673
Art. 5. Pessaries - - 674
Art. 6. Foreign bodies - - 678
Art. 7. Foreign bodies in the uterus 679
Art. 8. Uterine polypi - - 680
1. Tearing out - - - 682
2. Ligature - . . 683
Method of operation - - 683
Remarks - - - 685
3. Excision - . . 686
Method of operation - - 687
Art. 9. Cancer of the cervix uteri - 690
Anatomical remarks .- - 692
Amputation - . - 693
Method of operation - - 695
Art. 10. Extirpation of the matrix - 697
1. The uterus displaced - 699
The method of operation - 700
2. The uterus not displaced - 701
INDEX.
Art. 11. Veslco-va^nal fistula
1. Sutures
Method of operation
" of M. Lewziski
Catheters, crotchet forceps, &c.
Method of M. Dupuytren
" ofLaugier
2. Caxiterization
Art. 12. Recto-vaginal fistula
Suture -
Art. 13. Dystokia — difficult delivery
Symi)hyseotomy
Method of operation
Uterotomia abdominalis. Caesa-
rian operation
Metliod of operation
Art. 14. Vag-inal uterotomy
Chap. V. — The urinary apparatus -
Sect. I. — The operation of cutting for
stone - . . -
A. Stone in man
Diajrnosis . _ -
So'Mding
Ind -ations . - .
Art. 1. Stone by the perineum (the
appar.M is minor)
§1. A latomipal remarks
4 2. M thods of operation
1. Th ; lateral method (cystotomy
pro] r) ...
o. 1 rocedure of Antyllus and P.
^.^inetus ...
b. F rocedure of Brother Jacques
c. " of Raw
d. " ofCheselden
c. " of Foubert
/. « of Thomas
2. Median cutting. Apparatus ma-
jor - - - -
a. r rocedure of Mariano
h. " of Vacca Berling-
hicri - _ .
3. Oblifjue, or lateralized cutting
a. V ; ')cedure of Franco or d'Hu-
nai It
h. Procedure of Garengeot
c. " ofCheselden
d. " ofBoudou
c. ** ofLeDran
/ « ofLecat
f«« ofMoreau
« of F. Come
i. '* ofGuerin
j. « of Hawkins
k. ** of Thomson
/. ** of M. Boycr
4. Transversal, bi-lateral or bi-
oblique cutting
a. Procedure of Chaussier
b. « ofBeclard
c. " of Dupuytren
Page
707
707
708
710
710
711
711
712
715
716
718
718
719
722
727
729
731
731
731
732
732
737
738
738
743
744
744
745
746
746
746
747
747
748
749
750
750
751
751
752
752
752
753
753
754
756
757
758
759
760
761
761
d. Procedure of Senn
5. Quadri-lateral cutting
§ 3. Recapitulation of the methods of
operation in the different species
of perineal cutting
Apparatus
Staff
Forceps ...
Position of patient and assistants
Introduction and placing of the
staff
Cutting at two distinct intervals
Art. 2. Recto-vesical cutting (poste-
rior or inferior)
§ 1. Anatomical remarks
§ 2. Method of operation
Art. 3. Hypogastric cutting
§ 1. Anatomical remarks
§ 2. Examination of methods
1. Method of Rousset
of Douglas
of Cheselden
of Morand
of Le Dran, Winslow
of Baud ens
of Tanchou
^ of Verniere
2." « of Franco
3. « of Brother Come
§ 3. Method of operation
B. Cutting for stone in the female
Art. 1. Anatomical remarks
Art. 2. Examination of the methods
§ 1. Old procedures
a. Lateralized method or lateral
cutting
b. Method of Celsus and Lisfranc
c. Vesico-vaginal cutting
Method of operation
§ 2. Urethral methods
a. Method by dilatation
b. Urethrotomy
Art. 3. Estimate
C. Relative value of the different
ways of cutting for stone in the
male . _ ,
D. Nephrotomy
E. Stones stopped outside of the
bladder . _ .
1. Stones in tlie ureter
2. " in the thickness of the
vaginal septum
3. Stones in the pro.state
4. " in the Urethra
5. " between the glands and
prepuce ...
Sect. II.— Lithotrity
Art. 1. Historical
Art. 2. Examination of the methods
§ 1. Rectilinear method
a. Perforation
INDEX.
XI
b. Excavation
c. Concentric friction
d. Crushing'
e. Of the four ways of producing
trituration
§ 2. Curvilinear method
§ 3. Accessory apparatus
a. Position of the patient
b. Injections
c. Introduction of forceps
d. Finding the stone
e. Open the forceps
/. Find and seize the stone again
g. Apply the drill-bow
Art. 5. Remarks on some points in the
operation, and accidents in lithotrity
Art. 6. A comparison of cutting for
stone and lithotrity
Sect III.— The urethra
Art. 1. Catheterism
§1. Anatomical remarks
§ 2. Examination of methods and
instruments
Position of the surgeon and patient
Difficulties in the operation
Flexible catheters
The master-turn
Catheterism in the female
Art. 2. Stricture
§ 1. Forced catheterism
§ 2. Injections
§ 3. Incisions and scarifications of
the part strictured
§ 4. Concentric or external incisions
Page
Page
825
§5. Dilation -
859
825
§ 6. Cauterization
864
826
i 7. Abnormal dilation of the ure-
thra
870
827
Sect. IV.— Puncturing the bladder
871
828
Art. 1. Perineal puncture
871
830
Art. 2. Puncture through the rectum
872
831
Art. 3. Puncture above the pubis -
874
831
Art. 4. Mutual advantages and incon-
832
veniences of the species of puncture
875
832
Sect, v.— Fistulx urinaria^
877
832
Chap. VI. — Defecator organ
880
832
Sect. I. — Vices of structure
880
833
Art. 1. Imperforation
§ 1. Re-establishment of a natural
880
835
anus _ - .
881
§ 2. Establishment
883
839
Art. 2. Stricture
885
842
§1. Dilation
885
842
§ 2. Incision
887
842
§ 3. Cauterization
887
Sect. 2. Acquired lesions
887
845
Art. 1. Foreign bodies in the anus
887
846
Art. 2. Polypi
889
847
Art, 3. Hemorrhoidal tumors
889
849
Art 4. Prolapsus
891
851
Art. 5. Fissures
895
852
Art. 6. Fistula
896
853
§ 1. Anatomical remarks
897
853
§ 2. Examination of methods
900
855
A. Ligature
900
B. Operation, properly so called
901
856
Art. 7. Cancers
909
858
Metliod of operation
910
PREFACE.
In introducing a new treatise on operative surgery, my object is to meet a
want long felt by those engaged in the practice of that branch of medical
science. The work announced in 1813, by M. Roux, has not been completed.
The additions of MM. Sanson and Begin, to the inimitable work of Sabatier,,
cannot, notwithstanding their importance, supply the place of a book of this
character. The diagnostic and symptomatological details of almost every
disease requiring surgical aid, in which the author has indulged, have enlarged
his work, by encroaching on pathology to the injury of operative surgery.
The only object of M. Richerand, in publishing his nosographie, was to pre-
sent concise views of surgical science. M. Boyer, in confining his descrip-
tions to his own views of practice, has omitted many methods which should be
presented to the public. Besides, his work is not a special treatise on the
subject, and the eleven volumes which compose it, do not afford the student
a text book in the schools. A number of neglected operations, and others in-
vented since the time of Sabatier, and already known to the learned world,
have not yet found a place in our classic works. Rhinoplasm, chieloplasm,
blapharoplasm, otoplasm, bronchoplasm, staphyloraphy, torsion, puncture of
the arteries, lithotrity, cauterization of the urethra, amputation of the womb,
extirpation of the ovaria and of the anus, are among these operations. Indeed,
a review of the whole subject of operative surgery had become necessary from
the progress it has made and the changes it has undergone during the last
thirty years. My pursuits for the last ten years led me to the investigation
of the subject, and convinced me of the deficiency alluded to ; and I should
have attempted to remove the evil sooner, but I feared the task was beyond my
abilities. At first I conceived the idea of furnishing a simple manual ; but I
soon perceived that this course would increase the evil tendency of our young
students, to content themselves with every possible abridgment. The re-
searches which the undertaking required, have convinced me, under existing
circumstances, that in order to be useful to the faculty and the world, a trea-
tise must be full and complete, and not a mere manual.
Several volumes had been written when the journals announced the forthcom-
ing work of M. Lisfranc. I then thought of arresting my labors ; being pursuad-
ed that from long experience in the dissecting room, and hospitals, this emi-
xiii
XIV PREFACE.
nent surgeon would accomplish all that was wanting. Five or six years have
now passed away, and he has not fulfilled the expectations of an impatient
public. Feaiing that his numerous occupations would long deprive us of his
able and interesting researches, I have determined to prosecute my original
design. Another motive also induced me to postpone this work. Depending
solely on the experience of the anatomical colleges, my opinions then could
have been but of little value. Operations on the dead body could not be
adopted, until they had passed the ordeal of the hospitals. My situation at
that time, did not entitle me to the privilege of invoking my personal expe-
rience. But a practice of four years in the hospital of " perfectionnement,"
two years superintendence of the hospital of St, Anthony ; and the direction
of La Pitie since 1830, have enabled me to apply for the benetit of the living,
the experience acquired from frequent operations on the dead. I hope I may
be permitted to express an opinion on the propriety, either relative or absolute,
of the different methods of operating, which ought to be examined in a work
of this kind. Having witnessed the public practice of our great masters till
within a few years, there are few operations which I have not seen performed.
I have thus been enabled to compare the relative advantage of many of them,
and to judge understandingly on the reasons which they advanced in support
of the process they pursued, or against those measures which they condemned.
Writing for the sole interest of truth and science, I have examined the labors
of all without distinction of country, of school or of person ; reserving the
privilege of weighing their merits impartially, of drawing those deduc-
tions which naturally flowed from them, and in fine, of pointing out whatever
seemed to me either useful or injurious. Under this point of view, the pre-
sent epoch presents difficulties which can only be felt by those who wish to
produce an impartial history. Cotemporaries are rarely just to each other.
Animosity is too often transferred from the individual to the institution which
he may direct. Instead of being published by their authors, the improvements
and inventions, due for the most part to the great practitioners occupying the
domain of science, are only known by tradition, or by the efforts of candidates
impelled to defend the pretensions of their chief; it is indispensable in making
a conscientious critique, to investigate carefully true sources of information.
No work having yet been executed in this spirit — the surgical history of the
nineteenth century being yet in embryo — I have found it necessary to consult
a multitude of periodicals, private memoirs, and monographs of every de-
scription. A work of such great extent, in which all, should in some degree
assume the character of mathematical demonstration — treating of dates, of
inventions, of proceedings which gave origin to much discussion, of numerous
controversies of which the end and object of all have been presented in so
many different lights, interpreted in such a variety of versions, requires an
attention, a care, a literary labor, and an extent of research of which it is
difficult to form an idea without making the experiment. In executing this
work, I have derived great assistance from the General Archives of Medi-
cine, from the Universal Bulletin of Medical Sciences, and from the
Medical Gazette of Paris, which laterally has permitted nothing of interest
to escape the attention of its readers. The pages of the Lancet have
sometimes afforded me supplies. I can say the same of the Review, of the
Medical Transactions, of the Universal weekly Journal of Medicine, besides
PREFACE. Xt
every Journal, whether French or foreign, have been put in requisition.
La Bibliotheque Chirurgicale of Languenbeck, the Journal of Graefe and
Walthen, the Manual of M. Chelius, and the Treatise of Zang, have been very-
useful to me as regards the state of science in Germany ; and for the same
object, I have consulted the Medico-Chirurgical Review, the London Medi-
cal and Surgical Journal and the Lancet in England, where the classic works
are generally so inferior. In Philadelphia, the IMorth American Journal of
Sciences, &c., the Quarterly Journal &c., Dorsey's Abridgment, Sterlings
Appendix to my Treatise on Anatomy, are the sources I have had recourse to
in the United States. From the Annales Universelles of Milan, by M. Omodei,
and the Journal of M. Strambio, alone, I have been able to gather information
in relation to the medical affairs of Italy. The collections of Thesis at Paris,
Montpelier, and Strasburg, although too generally neglected, have afforded
me much valuable information. They contain a crowd of suggestions, of
propositions to which no attention was paid, of methods which have since been
advanced by different authors, and appropriated as original, because the real
author had retired and become forgotten in some distant province, where he
had not the means of reclaiming the honor of his discovery. In fine, that
nothing essential should be omitted, I have often addressed medical men
themselves, particularly those whose researches had not been published, or
those which had been written out by a third person. Thus, in order to be in-
formed about certain operations of M. Dupuytren, I have inquired of M.
Mark, his private student. By this means I learned that the disc-very of
the lachrymal duct originated in 1810, with the professor of the Ho^«l-Dieu,
operating on an invalid who had been afflicted for many years ; that he had
removed the inferior maxillary bone twenty times, and that the buperior
maxillary had been removed by him in 1813 ; that his process for am utating
at the shoulder joint dates in 1802; that he has tied the carotid four times
successfully since 1814; that it was in 1805, and not in 1810, he arplied a
ligature to the femoral artery for a fracture of the leg; that his first operation
for stone was {hypogastrique) at the Hotel-Dieu ; and that he had atiempted
lithotrity eight times.
It is unnecessary to mention here the aid derived from MM. Rou c, Rich-
erand, J. Cloquet, &c. having recorded it in the body of the work. The same
may be said of MM. Lauth of Strasburg, Ashmead of Philadelphia. Deleau,
G. Pelletan, Berard, Blandin, Pravaz, Leroy, Maingault, and many p -vincial
surgeons, to whom I am equally indebted. I learned also, from M. . louline
of Bordeaux, the success attributed to refrigeration in the treatment ;f aneu-
rism ; and nothing is more certain, than that all, or nearly all, the success was
due to the concurrent means not mentioned in the report. I would have
asked similar aid from M. Lisfranc, my colleague in the hospital la Pitie,
but knowing it was his intention to publish his own course of operative
surgery, I thought it would seem indiscreet, or that the request wt>uld be
disagreeable to him. Though very desirous of profiting by his labor- I have
concluded to derive my information from publications in the per )dicals,
either in his own name, or in that of his students ; in the Thesis sus<:r led for
fifteen years by the faculty, and in the Manual of M. Coster. In ord r not to
mutilate his ideas, I have used them with great reserve, hoping hereafter to be
able to present them in his own language.
XVI PREFACE.
In relation to the doctrine which is foreign to modern practice, I have
anxiou :ly endeavored to trace it to its source ; and this investigation has shown
me ho\ Sabatier himself and particularly Mr. Cooper have been so often led
into err ;)r, in giving the ideas of those authors whom they had consulted. Where
I couh; not attain my object from the scarcity of the works, or the foreign
langua e in which they were printed, I had recourse to the authority of
Spring e confirmed by Le Clerc, Freind, Dajardin, or of Peyrilhe, and what
is still more valuable, that of M. Deizeimeris, who, besides, on many occasions,
procun il me facilities and information which I could not obtain elsewhere,
and am >ng these I ought to mention the Historical Dictionary, with the praise,
too, wi'ch a book concientiously written justly merits.
I have scarcely mentioned a fractional part of the titles of the books and
entire .y omitted the papers I have consulted. It seems to me that the opposite
course, the advantages of which I would be the first to acknowledge, would
liave, i'l compiling a dogmatical treatise, a sufficient portion of inconveniences.
In the first place it would cramp the style ; 2, multiply its pages to an
iuordiiite degree; 3, burden the memory; and 4, encourage that imitative
learnin ;, which is now unfortunately too extensive in the French schools.
In abs ining from quoting the names of authors, I would have fallen into
an unf rtunate extreme, though most of our elementary books are composed
in this , 'ay. It is true the author finds the advantage of permitting the un-
learne(. to remain ignorant of the authorship of what he relates, and igno-
rance « ^ historical research will prevent detection ; but it seems to me nothing
can be more injurious to the true interests of science. Students seeing no
name i the text, attribute to the author in hand ideas that have been pro-
mulga (I for ages, or recorded by twenty different writers ; and thus become
unjust A^ithout being aware of the fact. Hence that credulity so skillfully
worke. upon for years, and more so than ever, at present, by the inventors of
new m 'thods : hence that academic mystification and that mode of fabricating
discov ries by numerous practitioners who are as liable to be mistaken astheir
pupils In attaching to each subject t discuss the principal authority connected
with it 1 acquit myself of blame by rendering rigorous justice. I have thought
that n y opinion would thus acquire an irresistible influence, and ultimately
that I should find my advantage in telling my readers in a single word,
wheth r the inventions they were examining were of a recent date, or had
been 1 )ng known to others. To those who reproach me with leaving it
impos.- ble to verify my quotations with precision, I would say, that in re-
cordin ^ the opinions of others, I have, in general, given them as I compre-
hende 1 them, without rendering others accountable for my interpretration.
Belie\ ng that I am addressing myself to students, I wish to let them under-
stand • hat there is such a thing as history, and to impress upon them a taste
for sci intific literature.
The compilation of this work is another point which requires some explana-
tions.
In performing surgical operations the importance of anatomical knowledge
has never been questioned ; nevertheless as it was impossible to embrace all
collate ral knowledge in a work on operative surgery, I have confined myself
to that which is indispensable, and have chosen a form which seemed best
adapted to an abridgment. Hence it is neither on the anatomy of the regions
nor no surgical anatomy, so called, that I have written, I have simply re-
PREFACE. XVii
counted in each operation, the points which were absolutely necessary — those
not essential I have passed unnoticed.
Sabatier, in other respects so perfect, who demonstrated science with such
clearness and precision, was, nevertheless, defective from his poverty in de-
scriptive details ; and can neither satisfy those who confine their studies to the
closet, nor those who practice in the anatomical schools. I have endeavored
to avoid this evil without loosing sight of the opposite inconvenience; well
aware how fatiguing from their dryness, and perplexing from their multipli-
city, are these interminable details which we find in many of the recent
publications. In fine, to satisfy all on this point, I have given to each case,
as far as the limits of the work would permit, the particulars, both practical
and mechanical, under the head of manuel operation^ absolutely useful in
performing an operation either on the living or the dead. The history, exami-
nation, discussion, appreciation of method, accidents, consequences and in-
dications, forming the subjects of so many distinct heads, will be a great
advantage to those who do not wish to read the whole article. I have used
these divisions only in complicated operations ; omitting them where the sub-
ject can be conveniently described in a few pages, unwilling either to treat
solely of the operative process, or to write a book on surgical pathology ; like
Sabatier, I have confined myself to the discussion of the indications, omitting,
without special necessity, whatever relates to the pathology, signs or general
treatment of disease. The comparison of methods, and of the results which
tjiey have furnished, form another question hitherto too much neglected but
of such unquestionable utility as to demand all possible attention.
If, in the course of my historical research, I have commented on operative
processes long since forgotten or justly proscribed ; if I have recorded a crowd
of recent inventions of no intrinsic merit, and useless to the cause of science 5
it is because, on the one hand, there is no process so singular but it may again
be revived by some new inventor, and, on the other, it is necessary to lay
before the student not only what he should adopt, but also what he should
reject in relation to the cotemporaneous history of data and opinions which
he will daily hear unjustly praised or condemned. Though I have, in this
double relation, endeavored to follow the course pursued by men of talents,
and to present with precision and impartiality, the actual condition of science ;
though I have neglected nothing in order to procure the best information
concerning modern improvements, still I fear that many useful points have
been overlooked. Upon this subject, as well as upon all others, I will cheer-
fully bow to the criticism of the learned.
The engravings are not as numerous as the nature of the subject seems to
render necessary; but the price of the work being already sufficiently high,
I thought it ought not to be increased. All have been taken from nature with
the greatest care, reduced in size, and marked with neatness and precision.
I have chosen such views as will exhibit at a single glance, the whole opera-
tion. The object being to supersede long graphic details, I have paid less
attention to richness and splendor than precision and clearness of design.
The execution has been confined to one of our most distinguished artists, M.
Chazal, well known for his talents in this line. The instruments which could
not be found in the Hall of the Faculty, were procured for me by MM.Char-
riere and Sirhenry, two of the most eminent surgical instrument makers of
C
XVlll PREFACE.
Paris. I cannot express too much gratitude for their kindness ; and also for
the politeness of the curators of the museum de L'Ecole, the MM. Thillaye.
At one time I decided to collect the plates into an atlas, and to annex an ex-
planatory text for the use of the amphitheatres ; and I thought it also possible
that I should make this subservient to another work on the same subject. The
drawings of M. Maingault on amputations, of M. Syme on resection or opera-
tion at the joints, of MM. Froriep, Manec on ligature of the arteries, of M.
DemoursandM.Weller on theeye,of M.Bretoneau and M. Bui Hard on trache-
otomy, of Scarpa on hernia, of MM. Anderson, Houston, Segalas, &c., on the
genito urinary organs, though more or less perfect in their kind, have been but
of little use to me. Among others, those of M. Manec did not make their
appearance till after the execution of my own, and besides being desirous of
presenting the objects in a new light, it was absolutely necessary that I should
have recourse to the dead subject. Lithotrity, staphyloraphy, &c., did not
present the same difficulties. And I have so freely used the lithography of
MM. Leroy, Civiale, Heurteloup, Tanchou, Tavernier, Roux and Schwerdt,
that I have often copied them exactly.
INTRODUCTION.
Definition. — In medicine the term operation may be defined an action
whose object is the amelioration of the organic condition of man. It is synon-
ymous with surgery ; but custom has given it a meaning, if not definite, at least
much more limited. At present surgery is translated by surgical pathology,
or rather pathological surgery, and embraces all diseases in the treatment of
which topical applications form the principal remedies ; while operative sur-
gery is confined to the therapeutics, which require the hand either alone or
armed with instruments. One is a true science scarcely different from medi-
cal pathology ; the other leans more towards the arts. The first can only be
advantageously pursued by those who are endowed with great aptitude for
intellectual exertion ; on the contrary, the hand is the indispensable and
characteristic agent in the second. But it is impossible to draw an exact line
of demarcation between them ; as we see them constantly encroaching on
each other in works purporting to be devoted to each.
If operative surgery is allowed to embrace rules for the application of cata-
plasms, plasters, ointments, leeches, cupping-glasses, blisters, moxas, acu-
puncturation, cauterization, seton, bleeding, &c. we cannot see why the
reduction of fractures and luxations, the study of splints and bandages
should be excluded. On the contrary case it is not less arbitrary in its point
of separation. Catheterism in general, the extraction of a foreign body either
from the ear or between the eyelids, the cutting of the frenum linguae, require
no more knowledge or address, than venesection or opening of an abscess.
The manner of dividing this science is merely a matter of courtesy, which
every man may construe according to his own views.
In omitting all that relates to dressings, treatment of wounds, &c. in order
to speak of operations, I have had no other motive than the necessity of fol-
lewing a path already pointed out by custom. These branches of surgery
having become the subject of special books which no student can dispense
with, by reproducing them I would have labored unprofitnbly, as the details
which my limits would have admitted could not supersede the special trea-
tises of MM. Legouas, Bourgery, and Gerdy on petty surgery and bandages.
Classification > — The necessity of dividing operations into a certain number
of classes has been felt at all times. The ancient classification laid down by
xix
XX INTRODUCTION.
Celsus who referred all to Dissresis, Synthesis, JExseresis^ or Prothesis, and
which prevailed during so many ages in nearly all the schools of Europe, can
no longer be maintained. In creating eight classes to supply their place Fer-
rein is still less successful. The reunion, the separation of tissues accident-
ally united, the dilatation and the re-establishment of natural canals, the
closing or obliteration of useless channels, the extraction of certain liquids,
amputations, extraction of foreign bodies, and reductions which he arranges
in so many different heads, form a division in effect the least natural that
could be imagined. DiarthrosiSy to remove deformities was added to the four
primitive orders since the time of Dionis. Dilatation and compression to
which M. Roux allows a separate place, and prothesis rejected by Ferrein, ap-
pear unworthy and but imperfectly fill the outline. The exploration of the
bladder, eustachian tube, and the lachrymal ducts, the injection of these dif-
ferent passages and simple torsion of the vessels for example, though important
operations, would find no place under any of the above divisions.
The efforts of Lassus and M. Rossi, to obviate the effects alluded to, have
been unsuccessful ; and the plan adopted lastly by Sabatier is attended with
so much trouble and inconvenience that no one will think of recurring to it.
Indeed, of what incoherences are we not made sensible when we see in treat-
ing of the eye, for instance : fistula of the corneoy hypopion, hydropthalmia,
staphyloma, scirrhus, procidentia of the iris, foreign bodies, cataract, and arti-
ficial pvpil, &c, scattered here and there to the middle of three volumes and
forming as many distinct divisions ? By this arrangement it would be almost
impossible to know where to find an article until we had previously waded
through an interminable index. In order to ascertain how to open the ante-
rior chamber of the eye, for instance, we would be compelled to consult by
turns the second, third, or fourth volume, according as it treated on the ex-
traction of pus, a foreign body, or the crystaline lens. In this point of view
the essay of Delpech is still more defective. Indeed, the method developed
by M. Richerand though one of the most advantageous for study, having
genius equally for its foundation, is not entirely exempt from the defects so
justly attributed to Sabatier. Hence it results that the topographical order
recommended by J. Fabricius, and followed by M. Boyer, notwithstanding
the repeated criticism, more or less just, to which it has been subjected, is still
in operative surgery the best, and, perhaps, the only course that can at present
be of any assistance to the reader. This is the only plan which conveys the
same ideas to every one. By its aid all will know where to find trepan,
cataract, empyema, lithotomy; whilst by following Sabatier or Delpech after
first inquiring whether such operations belonged rather to wounds and foreign
bodies, or to fractures and styptics, then to find in what order these different
heads had been classed in relation to each other. The pathology and cause
of disease, which render such divisions necessary, are too imperfectly known
or too variable to serve as a permanent foundation for the classification of
operations. In proceeding exclusively on the base of functional apparatus,
or the organic system, we depart from fixed rules it is true, but then we are
obliged to collocate the most incongruous subjects, (salivary fistula, abdominal
hernia, polypus of the rectum, &c.) or to separate others, (foreign bodies in
the trachea and oesophagus, tracheotomy, oesophagotomy, &c.) which have
the greatest analogy.
INTRODUCTION. '* XXI
We may present operations here under two general points of view : 1st, as
independent and classed according to their analogy or difference; 2d, as
therapeutic resources subject to the same divisions as the diseases which re-
quire them. In practice the first is applicable only to a few, such as trepan-
ning, amputation, ligature of the artery and suture. Incisions, extractions,
and special operations cannot properly be included. The second would be
still more difficult to generalize ; for if cataract, fistula lachrymalis, hare-lip,
&c., may be taken as the heads of chapters in operative surgery, why not
compound fractures, caries of the joints, gangrene, and gun-shot wounds, &c.
Seeing, from the difficulties against which all authors have in vain contended,
that it would be impossible to form a systematic classification, I have con-
cluded to adopt the plan least embarrassing to the students, though perhaps
least rational and less methodical. It is the only one, at least with some
slight modifications, that can be followed in the anatomical schools. Hence
I have undertaken to demonstrate, that the numerous operations of which the
human body is susceptible, may be exhibited without exception, on one sub-
ject. The desire of attaining this object, induced me to introduce ligature of
the arteries before amputations ; and to describe them from the extremity to
the trunk, without order or analogy. The operation of aneurism does not in
effect interfere with the process necessary to exhibit amputation ; while ampu-
tation would render it impossible to demonstrate the rules for the application
of ligatures on the vessels. If, instead of passing in review, the amputation
of the joints, the fingers, the hand, the wrist, the forearm, the elbow, the arm,
and shoulder, I had treated first of coniimcous and then of contiguous ampu-
tations, one subject could not have afforded the means of exhibiting all. Be-
sides, it seemed to me better to proceed with the trunk from the head to the
pelvis ; showing first the operation, then the diseases, then the organs or parts
subject to them, as the guide and standard. The only object in adopting this
method was to facilitate the study of the subject, and to aid as much as pos-
sible the memory of the reader ; it is cheerfully submitted to the criticism of
men of science.
Among operations all the data is given in advance, but no rules could
meet the difficulties of some operations. The first, generally termed regular
operations, are fortunately the most numerous and important. Under this
class may be ranged amputations, operations for aneurism by the method of
Anel, of harelip, of lithotomy, &c. The second comprehend tumors either can-
cerous or otherwise, which devel ope themselves on the scull, the face, the neck,
the axilla, the abdomen, and which require extirpation. There exists a third
class, which, in some degree, holds a middle rank ; such as cancer of the breast,
sarcocele, fistula in ano, hernia, re-sections* themselves, and the operation of
aneurism by the ancient method. We know well the parts to be divided when
operating for strangulated inguinal hernia; though we are often ignorant of
the pathological condition of the parts reduced. Thus operations naturally
divide themselves into three classes. In thejirst, the instrument acts on parts
entirely healthy or little deranged by disease ; in the second, it bears on points
the anatomical relations of which have been changed, or for the removal of a
tumor whose limits, if not naturally fixed, it is impossible at first to determine ;
and in the ilurd, it is applied to affections the limits of which are easily esta-
* Re-section, indicates the cutting- off the articular extremity of the long bones ; or
the ends of bones which do not unite after fracture. Tr.
XXU INTRODUCTION.
blished — surrounded by points fixed and known; but the varieties of wlii chare
too numerous for established rules of operating in one, to apply exactly to others
Process on the dead Body. — The convenience of this division essentially
practical, is thoroughly confirmed by experiments on the dead body. It is
possible, indeed, to exhibit completely the removal of members, ligatures of the
arteries, in a word, all operations that can be performed on the organs in their
normal state ; viz. on all of theirs/ class, nothing of the kind, however, could
take place in sarcoma of the face, maxillary sinus, amputation of the superior
maxillary, of the parotid gland, of the thyroid gland, the cyst of the ovaria or
the interior of the abdomen — in fine all of the second class. Every student
knows also that the knowledge acquired in the amphitheatres* of ligature of
the polypus, amputation of the neck of the uterus, operation for fistula in ano
orperineo, and of hernia particularly, is very imperfect, and but feeble aid
when called on to operate on the living patient. He would strangely deceive
himself were he to believe himself perfectly master of all operations, merely
from repeatedly witnessing the performance of them in the dissecting room.
No one can be a skilful surgeon without having a long time practised these
operations. They impart an aptitude, a steadiness, an address that the most
precise anatomical knowledge can never supply. But this is not all even for
operations of ih^ first class. If the eye is more flabby, more loose, less trans-
parent in the dead body, no idea of its mobility, of the tendency of thevitrous
humor to escape, of the eyelids to contract and of the tears which constantly
flow during life. When a limb is amputated, the tissues being more firm and
tense are more easily cut before than after death ; but in the latter case there
is no retraction of the muscles, no blood to disturb or annoy, and no difficulty
in ascertaining whether certain hemorrhage proceeds more from the veins than
the arteries. vSometimes, when an artery is deeply seated, it cannot be dis-
covered without dividing vascular ramifications, the blood from which so con-
ceals the parts as to render the distinction more or less embarrassing; whilst
on the dead body nothing analogous is to be met. The palpitation of the ves-
sels, which at the first glance would seem to afford precise information, is so
uncertain, so vague in regard to wounds, that very little advantage can be de-
rived from that source. In tracheotomy and a^sophagotomy, is it possible to
simulate the least portion of the embarrassment which arises from the plexus
of veins and the numerous arteries of the neck ? In passing to the two other
classes we must add their special, to these general difliicuities. We never
operate for fistula lachrymalis unless the angle of the eye is pasted up, ulcer-
ated, or more or less altered. It is the same more frequently in the nasal
fossa, when we are about to extract polypi. The motions of the throat, the
desire to vomit, the mucous or blood, the lassitude into which the patient each
moment falls, when we operate for hypertrophy of the amygdalas, bifurcation
of the veil of the palate, are never met with in operating on the dead body.
Caries and necrosis, which render excision of the joint absolutely necessary,
always change essentially the surrounding soft parts. Whence it follows that
there is no point of comparison between the process we are compelled to adopt
on the living patient, and the freedom of our experiment on the dead subject.
In each case, however, we know the number and situation of the tissues or
organs to be divided — the part to be raised or separated ; but suppose a mor-
bid mass of considerable volume becomes developed in the perineum, what
• The Lecture Room.
INTBODUCTION. XXlll
assistance would the surgeon derive from tlie experiments of the dissecting
room ? What I have said in relation to the perineum applies to the groin, the
axilla, the neck and every other part of the bod j. Without neglecting it, how-
ever, we ought to be careful and not attach too much importance to this species
of experience. Experiments on living animals though infinitel j more important
under this point of view, do not possess every advantage. In the first place
their formations being rarely alike, the results obtained by reasoning from the
analoo:y are generally defective. Hence, in order to study an operation with
the necessary care and judgment, it ought to be practised on the dead body,
and also on the living animal ; two sources of knowledge which mutually aid
without being able to supersede each othei".
Operative surgery is then definitely bounded— Jirst, on anatomy ; second, on
cadaverous experience ; third, on vivisection ; fourth, on pathological ana-
tomy ; and Jifth, on the habit of operating on the living man.
Methods. — As there are few operations which cannot be performed in dif-
ferent ways, I have thought proper thus early to explain, by an appropriate
word, the ensemble of which each method is composed. The terms, method,
process, mode^ have been indiscriminately used, and though nearly synonymous.
these three words are used still in a variety of circumstances. It has been
attempted, however, by M. Roux particularly to give each a distinct meaning.
The expression inethod, for example, is taken in a much more extensive sense
than the two others. Thus we say method, and not process or mode, in speak-
ing of extracting or covching the cateract; while in performing lithotomy with
the goro;et, use the term process and not method as indicated by the modified
operation adopted by M. Boyer. Ligature of the polypus is a method, but
ii2;ature of the polypus, according to the practice of such and such authors, is
0. process. In fine, we understand, generally, by the term method, some funda-
mental principle sufficiently extensive to be divided and variously modified ;
while the word process is more restrained, and is only used to designate the
diminution of some peculiar method. Nothing could more clearly prove the
propriety of these distinctions, than the operations for aneurism, for amputa-
tion, hydrocele, and lithotomy. To apply a ligature to the artery without
touching the tumor is called a method ; but place it higher or lower, and it is
called IX process. To open an abscess is denominated a method; the manner
ofopeninji; it is a ;)roce55. To resume — 7?ie^/iOfZ embraces the entire subject;
process relates to each of its modes of application. In common parlance,
therefore, it is necessary to adhere to these purely arbitrary terms ; and not
to use, as is frequently done in works more carefully written, the words pro-
cess, mode of operating in the place of method, and vice versa. Fistula lachry-
malis, among others, proves it completely; the term method being applied
indiscrimimitely to the process of Dupuytren, Desault, and Boyer. Hydro-
cele, hernia, and lithotomy are equally liable to the same remark. Process,
the method of cauterization and of injection ; method, the process of dilata-
tion and solution; process, the method of Frere Come are daily used. This
subject is one, however, of secondary importance; and in such a discussion
every one may reject or adopt these conventional terms, without being held to
account for it.
1st. Before the Operation* — The first object which demands the solicitude
of the surgeon before performing an operation, is its indications. It is on
XXIV INTRODUCTION.
this point that the most extensive and most precise medical knowledge is in-
dispensably necessary. After having satisfied himself that the cure can only be
effected by an operation, he should still be convinced of its utility, and also
that the patient incurred less danger in submitting to it, than in laboring under
the disease. Hence, it is only by the aid of a diagnosis, enlightened by the
clearest and most precise knowledge of pathological anatomy — of a prognosis
drawn from what the soundest judgment may apprehend of the progress or of
the probable issue of the organic derangements, and of an appreciation as
exact as possible of the power and value of the ordinary therapeutic agents
that the first problem can be solved. And, besides, none of its relations ap-
pears to me to be considered in a proper point of view. I wish to speak of
the choice to be made between the operation and the other therapeutic agents
which we may wish to substitute for it. Thus because the lachrymal tumor,
has lately been considered not within the domain of operative surgery, hav-
ing yielded sometimes to regimen and antiphlogistics — that certain tumors of
the breast having been dissipated by compression, it would be, in my opinion,
highly improper to conclude that all this treatment should precede in order to
render recourse to the knife unnecessary. Indeed, it does not concern us to
know if cancer, or any tumor whatever, can be removed by the action of such
and such medicines or by the knife ; but which, in the last resort, offers the
.'greatest advantages. I grant that the frequent application of leeches, emol-
lient cataplasms, abstinence, &c., cure a number of tu^^iors and even fistula
laclirymalis; but is it hence to be concluded that the treatment, whose suc-
cess is not even uniform, and requires to be continued several months, ought
to be substituted for a metallic tube in the nasal canal — a matter which is
effected in a second, removing in two days a disease of ten years standing,
and restoring the patient to health in a great majority of cases ? That leech-
ing and regimen may triumph over some masses apparently scirrhous or can-
cerous I will not deny ; but if these tumors remain movable and are favorably
situated who will assert that the bistoury will not remove them with much
more certainty and rapidity ? and by affecting less seriously the general phy-
siological condition of the system, diminish the sum total of human suffering.
What has been said in relation to cancer and fistula lachrymalis applies to a
number of other diseases ; forming the foundation of a remark that the sur-
geon ought never to lose sight of. If it is cruel to use the knife on those
who might be cured in a more gentle manner, it would still be less conform-
able to the interests of humanity to compromise the future health of the patient
under the vain pretext of averting a little present pain.
Nearly all the preparations to which patients were formerly subjected pre-
vious to operations have been abandoned by the moderns. Still there are
some which should be observed when the disease will permit delay. The
choice of season is not certainly a matter of indifference ; ceteris paribus,
spring and autumn ought to be preferred to winter and the heat of summer;
not because the temperature is more mild, but because the system is then
better able to resist general morbific variations. Thus it is rational and pru-
dent to postpone operations for the stone, cataract, the removal of large tumors,
and all operations which deeply affect the vital functions, till temperate sea-
sons; unless from some peculiarity of the patient, we have reason to pursue
another course. But too much importance is not to be attached to this pre-
INTRODUCTION. XXV
caution ; there is no time of itself capable of destroying the success of an
operation ; and the question of season is only an affair of better or lessfavor-
abU. No doubt the appearance of an epidemic should be a powerful reason
for temporizing ; and that the morbific conditions of the moment should be
regarded. In choosing the morning rather than the evening, the operator has
the advantage of finding his patient less fatigued, and he is better able to
watch his wants immediately after the operation ; but, besides this, there is
nothing that renders the morning indispensable, and the most plausible mo-
tive is that the forenoon is generally more convenient for all. As regards
urgent operations, they must be performed when exigency requires, without
reference to the seasons or hour ; and hence, authors have been led to establish
a time of choice and a time of necessity.
The moral precautions vary, and ought necessarily to vary, with the indivi-
duals. The first is, to inspire the patient with unlimited confidence in the
surgeon, and all that confidence is acquired in a thousand different ways.
The second is to convince the patient that the operation is the only means of
arresting his suf!*erings, and to disabuse his mind if he exaggerates the danger.
To resume it is necessary to do every thing, within the limits of truth, that
may induce the patient to desire the operation, if not with pleasure, at least
with resignation. There are two sorts of individuals to be encouraged on
this point. One is of extreme timidity, frightened at the idea of the slightest
stroke of the scalpel ; whom it is necessary to deceive as to the severity and
acuteness of the pain, and also to the dangers to which he is exposed. Tlie
others tliink that in public establishments the operation will be performed
nolens volens, and therefore never speak to the surgeon but with a disturbed
air ; and they remain under this delusion until the operator is able to remove
the error. Experience has discovered two other species of patients which
require to be well watched. In the first class we place those who doubt not
their risk, and who wishing to exhibit a bravado courage, submit themselves,
in spite of every one, to the knife of the operator, and pride themselves in sup-
porting the operation without complaint. The second class composes the
naturally timid or very susceptible, but who after long hesitation, have
become convinced that the operation is absolutely necessary, and collecting
all their courage, force themselves to withhold the scream, to resist the most
natural sufferings, and to stifle even the slightest complaint. To the first it
is necessary to manifest great seriousness on the subject which they appear to
treat so lightly and to decide after much reflection. An effort should be
made to convince the second that an affected courage never supplies the place
of real bravery ; also, that it is as dangerous to stifle complaints as it is to
exaggerate them ; that in suppressing them they do violence to nature, which
require that the cries of each suffering organ should be expressed freely and
without the least restraint. Besides, nothing augers so badly as these forced
resolutions and bragging of calmness or resignation. It seems as if nature is
weakened by this turning, as it were, on herself, instead of preparing to parry
the attacks. The fact is, that operations performed under such circum-
stances, terminate, generally, less favorably than others.
Internal Injuries. — It would be unprofitable to enter into an investigation of
the preparations in relation to injuries of this description, as it would tend to
complicate the principal diseases here spoken of. We never attempt any
D
XXVI INTRODUCTION.
operation, so long as the patient labors under any formidable functional dis-
ease, lest it should prove the means of terminating all the troubles of the
human economj. Besides, such injuries should be met as thej arise, before
or after having decided on an operation. The manner of recognizing and
treating them, having been necessarily laid down in books on pathology, it
would only be to abuse the patience of the reader to introduce them in a
work on operative surgery. The preparations are such as would be demanded
by the condition of the patient, in other respects in good health. Upon this
point authors are far from agreeing. Some prescribe scarcely a day's regi-
men, while others do not operate till after having used ptisans, purgatives,
revulsives, bleeding or a diet of the greatest rigor — in a word, of the most
minute precautions for one or two weeks. Hence, the difficulty of establish-
ing a general rule for all cases. It is in treating on the particular operation,
that this question ought to be touched. At present, I will merely remark,
that every operation sufficiently important to require a rigid diet for several
days afterwards, in order to control general re-action and imperceptibly to
cjjange the habits of the patient, require an antiphlogistic regimen, so far as
not to debilitate the patient ; that the soups and ptisans should be slightly
diluted and cooling; and that one or two bleedings either by the lancet or
leeches be resorted to. If the patient be robust, a purgative, or at least
laxative drinks should be given, in order that the transition be not too sudden
and that there remain no germ of morbid derangement in the system, except
what follows the operation itself. The preceding considerations ought to
apply to local prejmrations. The only thing necessary to be noticed here, is
that whatever supports the action of the instruments, the bandages or other
dressings ought to be carefully scraped and cleaned.
Place of Operation. — In hospitals, it is customary to remove the patient to
the amphitheatre, in order that his companions in misfortune may not witness
either his cries or the mutilation he undergoes. This place instituted for the
purpose, besides being very commodious, has no other inconvenience than that
it is more difficult to warm than an ordinary chamber; and it is the only one
which could enable the assistants to witness fully the skill of the operator.
It is only used, however, for the capital operations and a few others. Hydro-
cele, lithotomy, hernia, cataract, fistula lachrymalis and trepan, can, and ought
to, be frequently operated on in the hall or even where the patient lies. It is
only for lithotomy, amputations and the dissection of certain tumors, that the
amphitheatre is indispensably necessary. When the bed room of any patient
is not suitable for the operation, we should select some other place more
roomy, better lighted, and well ventilated. Here the assistants should be as
lew as possible, because those who are not actually employed, cause embar-
rassment almost always, by their indiscreet or ill-timed expressions, by
change of countenance, by vitiating the air of the chamber, or by restraint
on the patient or operator. The interest of students and of science require
the attendance of assistance in hospitals ; but here every thing being public,
the patients know beforehand what they have to submit to, and resign them-
selves to it without difficulty.
The assistants deserve the greatest attention, their number cannot be fixed ;
one being absolutely necessary, the others merely useful. In private practice
as few as possible are admitted ; while in public institutions all are employed
INTRODUCTION. XXVll
to wliom the operation affords the least advantage. In country practice there
is often a great want of assistants. Some of them may not have finished
their medical studies ; and to those are confided the duties which require only
strength, coolness, a little address or intelligence. It is necessary, also, that
each should be well acquainted with the duty he has to perform. The sur-
geon should be careful in making his selection in regard to the ability, saga-
city, stature and strength of those he entrusts ; and as far as possible to take
his assistants from the students accustomed to his practice, who can divine
his tiioughts at the least sign, and who have at heart the success of the opera-
tion, and the triumph of his labors.
The appareil or apparatus, is another point that should not be overlooked.
The materials which compose it are naturally divided into three orders. The
first, such as the garotte, tourniquet, pads, compresses, &c, are intended to
prevent accidents during the operation ; the second embraces all that is neces-
sary to perform it, and the third relates entirely to the dressings. There
should be in readiness, a sufficient number of flexible wax candles, rather than
lighted candles, in the event of the natural light not being sufficient;
2d, a chaffing dish full of coals and cauteries; 3d, a little wine, vinegar,
cologne and brandy in separate vessels ; 4th, tepid and cold water, basins
and sponges ; 5th, the means of suspending temporarily the flow of blood in
the parts about to undergo the operation ; 6th, several compresses, lint, ordi-
nary bandages, napkins to dress the patient or protect certain organs. The
second series comprehend the different instruments; such as bistouries,
knives, needles, scissors, saws, ligatures, nippers, pincers, &c, which are placed
on a waiter or table in the order in which they are to be used. The fillets,
pledgets, compresses, bandages and other dressings, are disposed on another
table so as to be at hand without confusion, when they are required for use.
Being about to recur to these details in treating of many operations, such as
amputations and aneurism among others, where their utility will be more
fully developed, it is unnecessary at present to enlarge on their advantages.
2d. During the Operation — The situation of the patient, of the surgeon
and his assistants, necessarily governed by the character of the operation, the
diseased organ and the taste of the operator, cannot be indicated more advan-
tageously than by describing each article. The same may be said of the
hemostatic means, either provisional or definite, of whatever is intended to
moderate pain, of the resources besides which have been mentioned under
the article " amputation."
3. After the Operation. — It is also important that care should be taken to
prevent syncope, convulsive movements or spasms, and in fact every attack
which may follow the operation. Being obliged to pass in review these vari-
ous chapters, so that the dressings, the question of knowing if the operation
will unite by the first intention, the accidents to which operations are princi-
pally exposed, and also the elementary points in the removal of members,
and of aneurism, it would be a waste of time to describe them here. I shall,
however, not stop to discuss the propriety of the ancient adage " cito tuto et
jiiciinde,'^ which formerly re-echoed throughout the schools.* To say that an
*This adag-e belongs to Ascepiades and not Celsus to whom it has been attributed. Hip-
pocrates and Galen say : Celerite^ jucundcy prompter et eleganter which amounts to tlie
MVlll INTRODUCTION.
operation should be conducted with promptitude, ability, and address, is a
truism which there is no occasion to repeat in our day : the most important
part is not to sacrifice one of these advantages to the other ; to look imme-
diately to the mind, and to show for example, that promptitude is neither pre-
cipitation nor swiftness ; but in surgery that safety and care should reign
paramount.
Phlebitcs or purulent Absorption. — The division of tissues by the hand of
the operator creates sometimes such a series of symptoms, which in latter
times has so much occupied the minds of scientific men, that it is impossible
to avoid entering upon its discussion more fully. The progress of disease
in similar cases is besides extremely variable ; sometimes it commences with
a violent trembling that may continue for many hours, sometimes by spasms,
and, in certain cases, simply by a coldness of the extremities. The skin
becomes pale, takes a yell()>4^ish tint, somewhat livid, and soon after an aspect
more or less ghastly. To the difierence of intermittent fevers produced from
low grounds, marshy places which have more than one trait of analogy, this
first period is rarely followed by a free re-action. If perspiration succeeds,
it is unequal, often clammy or heavy; after being renewed once or oftener
undei- the shape of paroxysms, these symptoms are generally followed by
remarkable adynamia and mortification. The eyes are sunk and covered with
greyish rheum, the conjunctiva becomes yellow, as well as the compass of
the lips, and the whole face remains more or less dull. The tongue which is
habitually moist, without being very large or pointed, as is the casein intes-
tinal affections, does not become, furred until at an advanced period of the dis-
ease ; the teeth and the lips become fuliginous. The pulse assumes a frequency
and hardness without being quick ; and becomes by degrees more and more
small and feeble. Distention of the abdomen, sometimes diarrhea, (seldom
delirium although nearly always stupor) scarcely ever fail to exhibit themselves.
To these are to be added the indefinite symptoms of visceral inflammation;
it appears occasionally as a livid redness of the cheek, which maybe remarked
for a moment, at the same time accompained by a slight cough or pain in the
breast, and difficulty of respiration ; sometimes as a jaundice, more or less
developed, with pain and derangement in the hepatic region or in the right
shoulder ; likewise, with what is more rare, a desire to vomit; with a par-
ticular redness of the lips and the borders of the tongue, which then becomes
dry, as in cases of follicular ulceration of the intestines or of typhoid fevers ;
as well, in fine, as by acute suffering in some part of the members of the body
— the great joints for example. Thirst, is not generally very great ; the
breath, often fetid, exhales sometimes the true odor of pus ; the process of
cicatrization is immediately suspended in the wound, the borders of which
become pale the same as the rest of the surface. However thick or creamy
it might have been, the suppuration becomes all at once greyish, clotted, or
resembling ill conditioned serous matter. It is not rare to see it stop sud-
denly. The soft parts shrink up with iht same rapidity, and assume the
most cadaverous aspects. The muscles, bones, &c., fall asunder, as if the
cellular tissue which unites them in the normal state had been destroyed;
after a while a bloody oozing ensues, which becomes more and more fluid
until it terminates, when the malady has lasted a long time, by resembling the
washings of meat, and produces hemorrhages which nothing can arrest. In
INTRODUCTION. XXIX
fine, Ihe subject dies exhausted on the twelfth, thirteenth, or fourteenth
day.*
Pathological Anatomy. — Upon the opening of dead bodies, lesions of
different sorts are found, although susceptible of being all traced to the same
cause ; these are often the seats of multiplied abscesses, in the proper tissue
of the viscera, or collections more or less abundant of greyish cream colored
serosity, rather than flakes floating in the serous cavities. Among others the
large articulations, such as the shoulder, the hip, the knee, are equally filled
with pus, which is supplied frequently, either by the state of the parts
or by infiltration, particularly when there is a sufficient quantity of
lax cellular tissue. The arteries are almost empty, and the blood which
they contain is in general very fluid ; that of the veins, which is more
abundant, is still more evidently altered. The clots which are found here
and there, are a mixture of black, yellow, white and green, and have a
granulated texture, which escapes in cutting or even in pressing them under
the fingers. They contain sometimes globules of pus, obvious to the naked
eye. It is not even rare to meet with the true purulent foci in small clots of
blood. All the parts of the venous system have offered specimens of this de-
scription; as, for instance, the iliac and uterine veins, the vena-cava inferior
below the liver, and at its entrance into the right auiicle, the vena-cava supe-
rior, the different cavities of the heart, &c. Many of these concretions are
yet soft and evidently of recent origin, others, on the contrary, are so dry and
brittle that it is impossible to deny them a certain age. Not one of them has,
in a majority of cases, a pathological relation to the state of vessels in the re-
gion in which it is found. It is entirely different, in the case of wounds,
where nothing is more common than to see the veins inflamed, in full
suppuration, either interiorly or exteriorly, and that to an extent extremely
variable, but of such a description, however, that the two vense-cavas remain in
almost ever J instance unaffected.
The small abscesses of which I have spoken in the commencement, have
been observed in all the organs. A subject which I had occasion to examine
at Tours, in 1808, presented them by dozens in the brain and in the tissues
of the heart. A young man who died at the Clinique of the faculty, in 1825,
from the effect of amputation of the great toe, exhibited them even in the
spleen and in the kidneys. The lungs and the liver, are not less subject to
them. It is there that at all times it has been known to exist when no trace
whatever could be found elsewhere. Their characters are so well marked,
that it is difficult to confound them with the results of ordinary inflammation.
Besides, they are seldom developed singly, but much oftener a large number
exist in the same part. The surface of the organs appears to be more congenial
to them, than deep seated parts ; and it is rare that they acquire any great
size. In this point of view they vary from the size of a pin's head, to that of
a walnut or of a small egg. By pressing upon them they can be distinguished
as so many large tubercles reaching across the pulmonary apparatus, the
periphery of which seems quite superficial. In the liver they are enveloped
in a blackish or livid couche, sometimes several lines in thickness. In this
organ they are situated most commonly near the centre, and are generally of
* In the text it is the twelfth, thirtieth, or fortieth day. Tr.
XXX IKTRODUCTION.
a larger size than in the other parenchymae. The matter of which they are
formed is also more irregular. Although generally very fluid, blue, and
flaky, or of a milky whiteness near the centre, they are very often grumous
or even hard especially near the circumference. In the lungs we may wit-
ness the various phases of this affection still better. At some points may be
discovered slight stains resembling ecchymosis. In others we see these stains
or blotches inclosing a drop of pus. Again, no ecchymosis exists, and nothing
but grumous pus is to be found. Still further we meet with others either
concrete like the caseous tubercles of lymphatic ganglions, or liquid as in the
liver. The substance of some seems to be confounded with the neighboring
tissues. Others are as if encysted. Then the walls of the sac are villous and
of a lilac color. At some lines distance from them the organ recovers all the
attributes of its normal state. They are almost always separated by inter-
val completely healthy. Frequently it appears after evacuating the matter
and removing the cyst as if the organ had never been diseased, or as if the
places of the disease had been formed mechanically by a separation of the
tissues.
The eftusion in the serous cavities is also very remarkable. The pleura is
generally its seat although it may also take place in the pericardium, perito-
neum, arachnoid membrane, &c. In a few days it becomes very abundant.
Without scarcely any alteration the membrane after being emptied, remains
covered with a greater or less thickness of true pus, and the residue of the
liquid, of an ashy or earthy appearance, is far from resembling the flaky or
lactescent serosity which is found as a sequence of recent pleurisy. The
state of the tissues in the articulations is astonishing. Neither the cartilages,
ihe capsules, the ligaments, the cellular envelope, nor any thing, in a word,
presents the least trace of inflammation, and after removal of the pus a sim-
ple lavation has been sufficient more than once to cause doubt whether or not
the articulation had been diseased. It may even happen that the cartilages
may be partially destroyed, the synovial membrane and the ligaments pierced
without the contiguous parts losing any of their mobility or natural color.
The same may be said of the sub-cutaneous and other deposites in the extre-
flriities. In other cases these- deposits are surrounded by ecchymosis and
more or less evident traces of inflammation.
Although some patients die with all these varieties at once, imbibing pus as
it were like a sponge, the greatest number exhibit only a part of them. Some-
times they are tubercle-like as in the lungs or liver, without any efiusion.
Sometimes collection in the pleura exists alone; in another case this may be
found in the extremities, within or without the articulations ; in many cases
it will be found no where, and then we must seek the cause of death in the
more or less serious alteration of the blood in the vessels themselves.
Etiology. — Every solution of continuity that suppurates, may produce the
alterations that we have just spoken of: trepaning, a simple incision, the sec-
tion of a varix, an ordinary venesection, as well as the amputation of the neck
of the womb, the excision of hemorrhoidal tumors, or the amputation of a
member. Nor is this a discovery of the present day. Pare mentioned it,
and Pigrai says, that in a certain year almost all that died of wounds of the
head had abscesses of the liver. Morgagni describes these affections with
some detail, Quesnay, Col. de Villars formally mentions them. J. L. Petit
INTRODUCTION. XXXI
gives a very correct idea of them, and many modern surgeons have noticed
them in their lectures or their writings, but they had not then fixed the at-
tention of the profession so strongly to their importance as they now do. In
saying that the pus was transported from the wound to the organ in which it
was found deposited, the ancients merely reiterated their usual humoral hy-
pothesis and proved nothing To believe as MM. Boyer, Roux, and Dupuy-
tren did, that so many disorders result from simple idiopathic inflammation,
caused itself by the sympathetic (retentisment) of the wounded part upon the
viscera, or by the anterior existence of tubercles or other organic lesion un*
appreciable until then, was not likely to excite a very lively interest in the
question. Struck, at the commencement of my medical studies with the fre-
quence and importance of these aifections I soon made them the object of my
special attention. Believing from a fact observed in the hospital of Tours in
1818, that I had discovered the true etiology, and confirmed in this opinion
by what I afterwards met either in Tours or Paris, I took the liberty of
publishing it in my public lectures in 1821 and 1822, and in my Tliesis de
Reception in 1823. I then maintained that these numerous purulent depo-
sites owed their existence not to any separate idiopathic phlegmasia, but to an
alteration of the blood, to the passage of pus into the circulation and its trans-
port into these organs, whether it came from the wound or was secreted by
the neighboring veins. It required some boldness to advance such idea then
whilst solidism reigned triumphant over our schools, from which the partisans
of the physiological doctrine thought they had for ever banished humoralism.
These ideas were therefore badly received generally. Yet my own convic-
tion and the facts that came daily to their support did not permit me to
abandon them. My sojourn at the hospital de Perfectionnement furnished me
numerous. occasions to submit them to new proofs, to call them to the atten-
tion of the students, and to show in what manner they might enlarge the field
of general pathology. The two memoirs that I published in 1826 in the Re-
view upon this subject, and that which I had already said in the same journal
in treating of the alteration of the fluids ; that which I had advanced at the
same time, or soon after, in the Archives and La Clinique des Hospitaux, and the
discussions that I caused in the Academy finally had its effect, and I soon had
the satisfaction to see that Marechal and Raymond of Marseilles, in their ex-
cellent thesis (1828) and M. Legallois in a memoir at the same time had
arrived at the same conclusions that I did. Whilst M. Dance in a work stiU
more complete, was removing the last vestiges of objection, opinions supported by'
facts of the same kind were taught at London by MM. Rose and Arnott. M.
Blandin, who in a thesis a little later than mine (1824) had adopted the hy-
pothesis of sympathetic reaction and pure simple inflammation — MM. Tonnelc
and M. Rochoux have ranged themselves under the same flag although their
tkeoretical views are not exactly alike. In fine, the pathological meeting
which took place at the Faculte de Medicine in the spring of 1831, having
called in MM. Berard, Blandin, Sanson, and myself, to examine the question
c(f metastatic suppurations following traumatic lesions, has in a manner
forced us to show the present state of opinion upon this subject, and to provfe
that there can be no further difference of opinion upon the principle with which
I set out, viz. that metastatic abscesses caused by great operations are the result
of an alteration of the blood.
XXXll INTRODUCTION.
There is still, however, a problem to solve. Marechal, Legallois, and
Rochoux, found in the absorption of the pus of the wound a sufficient expla-
nation of all the observed phenomena. Dance, Arnott, and Blandin on the
contrary thought that an inflammation of the veins always preceded the gene-
ral infection, and that the pus which entered into the circulation was always
the immediate product of phlebetis, which M. Blandin located in the veinules
of the soft parts, the medullary canal, or the spongy tissue of the divided bone,
when the primitive branches offered no traces of the affection. Instead of j
admitting a transport without decomposition, a true metastatic deposite,
the latter authors think also that the blood, profoundly altered by its intimate
intermixture with the pathological secretion, and becoming more irritating
than common, is simply permitted to escape here and there ; and being depo-
sited in the tissues, by their irritation become the centre of so many points of
suppuration. This opinion differs from mine only in this, that it gives a cause
as the constant one, which I think exists only in certain cases. Nor can I
comprehend how any one can expect to make use of the labors and opinions
of MM. Dance and Blandin to combat mine. In fact, so far from denying
phlebetis in such cases, I expressly said in 1826, (Rev. Med. tom. 4j "the
veins of the diseased member are full of a very fluid greyish pus, and inflamed
from point to point, but only as far as the entrance of the great saphena into
the crural." Again, I added, '* the phlebetis was not sufficiently extensive ;
if it were even primitive to play an important part as inflammation. In turn-
ing our attention towards the fluids, on the contrary, every thing explains it-
self in the clearest manner," &c. In May 1827, I asserted (C Unique des
Hopit,) that " in this frightful affection authors have paid attention only to
one cause of danger; the facility with which the inflammation is propagated
from the wounded point towards the principal veinous trunks ; whilst the pus
secreted by the walls of the vessels continually mingles with the blood which
it alters and decomposes, and thereby produces all the danger of the disease."
Finally, in speaking of the same fact in the Archives (August 1827,) I said,
** here the disease was incontestably a phlebetis ; but it is to the inflammation
of the vein that we must attribute all the symptoms. I think not: the pus
continually entering the heart and distributed to every organ with the blood
has produced the general affection," &c. As to the formation of the purulent
collections, this is my theory which I gave in 1826, (Rev. Med., tom. 4.) " It
is possible to explain the formation of these collections by two processes;
1st, the blood more or less changed from its natural condition, may commence
by deranging the general organism, and terminate by the formation of a local
phlegmasia of a peculiar species ; or, 2d, the inflammation at first developed
under the influence of ordinary causes compels pus in a manner to be depo-
sited at the point of the greatest irritation. It appears to me demonstrated
that the inflammation when it follows the deposition is then only secondary,
and that it is produced by an extravasated portion of foreign matter, which
forms the point, and that this is at least a phlegmasia altogether sui gene-
ris,'' &c.
Thus, in my opinion, the question may be reduced under two heads ; 1st,
the mixture of pus with the blood as the cause of the observed visceral altera-
tions; 2d, the origin of the pus whether in the blood or in the organs. The
first, of which I was the first to venture on the demonstration of its truth, [%
INTRODUCTION. XDdSL
now generally admitted as incontestable. For the other I have not felt the
same interest it is true. The object of my efforts being to prove that the pus
could circulate with the blood, and infect the system like a poison, I cared
little at the moment about proving whether it penetrated into the veins by ab-
sorption or was simply formed on the inflamed surface of these canals, pro-
vided it was admitted to be transported a certain distance from the point of
departure. The preceding quotations, however, are sufficient to show that I
had not altogether neglected these secondary questions. The effect of phle-
betis upon the composition of the blood are so evident that it appeared to me
superfluous to enter into any detail for their exhibition. The same cannot be
said of absorption, as many yet refuse to admit it ; it is, therefore, after leaving
this part of the question, that a real difference seems to exist between M.
Dance and myself. According to this author, the phlebetis is the first and
almost only cause of these metastatic /od, and the veins alone secrete the
pus that alters the blood. On the contrary, I said at first, as I believe now,
that the inflammation of the veins so often met with, whether cause or effect,
were not indispensable; that the pus and other morbid matters of the trau-
matic surface enters sometimes into the circulation, either by lymphatic absorp-
tion, by imbibition, or by the orifices of the veins remaining patulent at the
amputated surface. The proof of its truth, in my opinion, is, that I have
frequently found abundance of pus in the midst of the viscera although the
veins plunging into the exterior lesion were scarcely phlogosed, and without
any trace of phlebetis at any other point of their whole course. And since
the possibility of this has been denied, I have proven it upon thirteen sub-
jects ; among others, in a woman who died in consequence of a serious trau-
matic lesion of the foot at the hospital Saint Antoine in 1829, who was opened
in presence of M. Dezeimeris, an avowed partizan of M. Dance's ideas ; and
again, upon one of the wounded heroes of July, who died on the twentieth day
of an amputation of the thigh in 1830, at la Pitie, in which I exhibited tlie
total absence of phlebetis to M. Berard, who had also adopted the hypothesis
of veinous phlegmasia as the first cause of metastatic abscesses.
As to the mechanism of these abscesses themselves, I said that the pus tra-
versing the tissues might be deposited naturally, or by its presence irritate
sevei-al points of the viscera, and thus form so many phlegmasia! and puru-
lent foci. M. Dance rejects the first of these two modes, and seems even to
deny its possibility. With all the reasoning and objections that he produces,
I cannot submit to his opinion. If he thinks that the blood, rendered more
fluid and altered by the pus, begins always by producing a small echymosis,
and soon after a true inflammation, before producing an abscess — ^a mechanism
that I have pointed out myself for the majority of cases — then he has not
seen, as I have, these foci, not larger than a hemp seed, in the head, the
spleen, the kidneys, the lungs, and the liver, and around which the most atten-
tive and minute examination, did not enable me to discover the least lesion of
the organic elements ; nor those purulent collections that I have so frequently
met with in the cellular tissues or certain articulations, and which after eva-
cuation and lavation, leaves not the least trace of their existence. If the little
veins around each purulent focus are sometimes inflamed it is certainly erro-
neous to say that they are always so, and we may admit the capillary phlebetis
pointed out by M. Cruveilher as happening in similar cases. Moreover, if we
E
XXXIV INTRODUCTION.
admit the deposition of one molecule of morbid matter, we cannot refuse to
admit that there may be a great number. The pus mingled with the blood is
a heterogeneous matter, which tends continually to escape by one way or
another. Whilst it is inclosed in the large vessels, and the circulation has
lost nothing of its activity it injures nothing; but in the capillary system
where the movement of the fluids are only a sort of oscillation, where are
produced nutrition, the various secretions, a thousand new combinations,
compositions, and decompositions, must not its elements make some efforts to
agglomerate, to reunite, and cease to flow with the other fluids ? This chemi-
cal aggregation made, will it not constitute a centre of attraction for other
similar molecules ? Is any thing else necessary to determine the seat of an ab-
scess ? There is nothing in this more difficult to comprehend than in the
formation of bile, urine, saliva, or mucus. These are natural secretions and
exhalations ; that on the contrary, is a pathologic secretion or exhalation. This
is all the difference.
Prognostic. — Let the matter be explained as it may, these metastatic
collections, are the effect of serious operations, and always produced by the
passage of a certain quantity of pus into the general circulation ; and thereby
justifying an extremely unfavorable prognostication. The name tuberculous
that I first gave these collections, related to their form, and I am astonished
tliat any person should have attributed to me the idea of comparing them to
tfie tubercles of the lungs under any other aspect. The silent and often rapid
march of these lesions rarely permits us to detect them in their origin, and
when at last the fact of their existence is no longer doubtful, they are gene-
rally beyond the reach of art. As soon as the surgeon discovers the existence
of violent chills with alteration in the expression of the face, a continued
fever, whether attended or not by pains in certain parts of the body, or whe-
ther following or not following a diarrhea, in a patient recently operated
upon, or who is suffering from an extensive suppuration of any kind, attended
with traumatic lesion, he may expect the most serious consequences and fear
that death will be the inevitable termination. Yet, if such phenomena exist
'only for two or three days, and at the end of this time a general sweat or some
other critical evacuation extinguishes the fever and calms the above men-
tioned organic derangements, he will have some cause to hope. I have seen
persons recover after having had the true shiverings as well as other symptoms of
a purulent infection. The examples are rare, it is true, but they have occur-
red, and the surgeon should not forget them.
The mode of treatment is yet unsettled. Sanguinary evacuations either by
phlebotomy, leeching, or cupping, is only applicable in the onset of the
disease, and in robust and plethoric cases, unless there be some pain or well
determined local inflammation j I have seen them used and pushed as far as
possible in a number of cases without discovering any sensible advantages.
Those who have suffered from hemorrhage either of the wound or the mucous
surfaces were not more fortunate. Purgatives administered early, have ap-
peared to luc to succeed sometimes. Vesication either of the thighs, legs, or
painful parts of the chest or abdomen, deserves to be remembered. Nor is
tiie sulphate of quinine without some utility when there arc any intermissions
and the stomach not too irritable. Tartrite of antimony, in large doses, first
recommended by Laennec, and since by M. Sanson, did not prevent the death
INTRODUCTION. XTTt
of three patients on whom I tried it. As to the preparations of opium, cam-
phor, ether, ammonia, and other diffusible and exciting substances, they have
' always appeared to me to increase the symptoms, and hasten the fatal ter-
mination.
Finally, when the derangements above indicated manifest themselves, every
exertion should be made to attract the fluids towards the wound. If it be an
amputation, it should be first enveloped night and morning in a large linseed
cataplasm, applied naked to the skin. At the same time, one or more blisters
are to be applied to the legs, and a light warm infusion of linden or elder pre-
scribed as a drink. A bleeding to the extent of eight or* ten ounces if the
pulse has sufficient force, or the patient be not already too weak. If the
wound be very pale and the tissues have lost their consistency, it will be ne-
cessary at each dressing to make use of a lotion strongly charged with
cinchona, and then cover it with a pledget of storax or of balsam d'Arcceus,
mixed with cerate. A blister to the stump, scarification, and leeching, if
there be at the onset any swelling, inflammation, or external evidence of
phlebetis, will be indicated. Compression by means of a roller from
the origin of the m.ember towards the solution of continuity should also be
tried if the disease has not affected the system and is still local. After
these Seidlitz water may be administered as a purgative if the tongue con-
tinue soft and not red. The stimulant emetic should only be used after-
wards, when stupor, swelling of the abdomen, and a fuliginous state of the
mouth have made their appearance. Cinchona, either in decoction or substance,
is only to be used in well marked adynamia. Gum, and rice water should be
combined withitwhen diarrhea exists, or when the digestive tube seems disposed
to revolt against it. The sulphate of quinine in a dose of five or eight grains at
the termination of each paroxysm will answer better if there be intermission
and sweat. The drinks must be varied according to the predominating symp-
toms and the taste of the patient. Such as lemonade, decoction of tamarinds,
&c., rf the thirst be great, or light bitter aromatic infusions in the contrary
case. The decoctions of rice, barley, ratany, the white decoction, disascor-
dium, gum kino catechu, or extract of ratany are no longer to be dispensed
with when the alvine evacuations are frequent and threatening to the patient.
In a word, the whole of this treatment being exactly the same as that for
phlebetis, and the absorption of pus in general can only be incompletely ex-
posed here. The details must be sought in the treatises on pathology. I have
only felt it necessary to give a summary, such as was indispensable to excite
the solicitude of the surgeon, and premonish him against the dangers of a
false security in the therepeutics whose eflficacy is still so uncertain.
NEW ELEMENTS
OPERATIVE SURGERY.
ELEMENTARY OPERATIONS.
The greater number of operations are made up of several separate steps, each
of which often constitutes in itself a distinct operation. Throughout operative
surgery are found, incisions, dilatations, extractions, and reunions, whether
separate or variously combined. As dilatation and extraction require in each of
the particular operations in which they are practised different instruments or
processes, it would be superfluous to examine them here as general indications.
But, there are few operations which do not be^in by a division, or do not end
in a reunion. I have thought it best therefore to begin by saying a few
words of diarjesis and syntheses.
CHAPTER I.
DIVISIONS.
SECTION I.
Cutting Instruments.
Laying aside laceration, pulling out, and rupture, which nevertheless are
also divisions, diaeresis requires no other agents than the bistoury, the
scissors, and certain instruments designed to answer particular indications.
ARTICLE I.
Manner of Holding the Bistoury,
The bistoury is of itself worth all the rest of the surgeon's armory. If it
were absolutely necessary, it could supply the place of all other cutting
instruments. To use it skillfully then, is an art which the surgeon should
make it his first endeavor to acquire. There are three principal ways of
holding the instrument; first as a table knife, secondly as you would hold sl
S NEW ELEMENTS OF
h
pen, and thirdly as a drill -bow. Each of these modes presents varieties
which I intend briefly to point out, giving to each the name of position.
FIRST POSITION.
Bistoury held as a Knife, the Edge downwards.
In this, which is the most frequent position, the handle of the instrument
enclosed in the palm of the hand, and retained there by the ring and little
fingers, is pressed on either side by the thumb and middle finger, at the
junction of the blade with the handle, whilst the fore-finger rests upon the
back of the blade: thus held, it presents the utmost firmness and security,
and it can be guided in every possible direction ; if it is necessary to employ
much force, to cut into solid tissue, to cut out large flaps or vast and indu-
rated tumors, or to pair off" some dense excrescence, nothing would be easier
than to bring the middle and index fingers before the others, upon the side of
tlie handle, and to hold the instrument in full grasp.
SECOND POSITION.
Bistoury held as a Knife, the Edge upwards.
Instead of being held towards the tissues, as in the preceding position, the
edge of the bistoury should be sometimes turned in the contrary direction.
In that case, the front and not the back part of the handle is pressed against
the palm of the hand, and the thumb with the fore-finger presses the sides,
while the middle is beneath the handle with the third and little fingers.
Thus, turned upwards, or in the direction of the back of the hand, it is in
the best position for cutting from within outwards, in certain cases where
more force than celerity is required in the movement.
THIRD POSITION.
Bistoury held as a Pen, the Edge downwards and the Point forwards.
In this position the handle of the bistoury passes from the back of the hand
on the radial side of the first metacarpal bone, to be held as in the fii-st
position by the thumb and the first two fingers. The remaining fingers are
left free to find some point of rest near the part to be divided.
FOURTH POSITION.
Bistoury held as a Pen, the Point backwards.
If the edge of the instrument be turned towards the tissue, and the point
directed forwards, it will be found to be held exactly in the same manner as
a pen, and this is the characteristic of the preceding position.
Manner of Holding the Bistoury.
But, in the fourth position, the middle finger is pushed forwards on one
side of the blade, and then flexed, turning the point of the instrument by this
OPERATIVE SURGERY. • 3
motion towards the body or wrist of the operator, so that its edge looks
towards the palm of the hand, from which it is separated by a triangular
space varying in the dimensions of its posterior base. The greater part of
delicate incisions and dissections require the first mode ; the second is more
applicable when it is necessary to pierce some deep part, and cut outwards
from the puncture.
FIFTH POSITION.
Bistoury held as a Pen, the Edge upwards.
To dissect or to cut forwards, in order to enlarge certain openings which
are deeply situated, we are often obliged to change the position of the edge
of the bistoury, and turn it in the same direction with the dorsel aspect of the
hand, and to present the back towards the palmar side ; and except that it is
necessary to substitute the index for the middle finger, the instrument may
be held with the point either forwards or towards the wrist of the operator, as
the fingers may be flexed or extended, and as it may be desirable to carry a
continued incision, or merely to divide attachments.
SIXTH POSITION.
Bistoury held as a Drill-bow.
The sixth position holds in some sort a middle place between the first and
the second. As in the one, the handle of the instr^iment rests on the interior
of the hand, and as in the other, it is held only by the ends of the fingers.
This mode differs nevertheless from both in the fact, that with regard
to the axis of the fore-arm, the bistoury is held in a horizontal plane, and that
the pulp of the extended fingers supports it on one side, whilst the thumb is
applied upon the other. The three varieties of this position are easily
distinguished. In the first, the edge of the bistoury looks downwards. In
the second variety, which approaches nearer to the second position^ it is turned
upwards, and in the third, it is turned to the riglit or the left, while, instead
of holding the handle by its flat faces, the finders and the thumb press against
the back and front. The first of these positions, giving facility to light and
delicate strokes, is particularly indicated in scarifications, such as of inflam-
matory erysipelas, where we have decided to operate by incisions, and also
for laying open large subcutaneous abscesses. Recourse is rarely had to the
second position, unless for the purpose of cutting small lamellae, guiding the
bistoury along the groove of a director. The utility of the third position
also, is only acknowledged in a small number of cases, when, for fear of
wounding some subjacent organs, it is thought necessary to cut horizontally'
by successive laminae, as in the operation of planing.
Manner of holding the Scissors.
The manner of holding the scissors is familiar to all. It is not necessary
for me to point it out. I will only say, that instead of the index or middle
finger, the fourth or little finger and the thumb should hold the rings of the
instrument ; the two first fingers being placed before, either about the handles,
or upon one of the flat faces, add to the firmness and precision of the move-
ments. The use of knives, or of particular bistouries, will not be described
except in connexion witli the operations which require them.
4 NEW ELEMENTS OF
SECTION II.
Different Kinds of Incisions.
All incisions are made in one or other of two general modes, the
definition of which will serve as a principle of classification. The first class
of incisions consists of those which are made from the skin towards the deep
parts, and is called from without inwards; the other class, are those which
are made from the midst of the or2;ans towards the exterior, and are called
incisions from within outwards. The choice of the first or second of these
modes must be decided by a variety of circumstances, whicii will in their
proper order be developed in the sequel, and which will, in the discussion of the
opening of abscesses, be in a great measure recapitulated. Whichever method
is adopted, incision is practiced: first, towards the operator; secondly, from
the operator ; thirdly, from left to righty when the handle or point of the bistoury
is directed either immediately across, or obliquely backwards and outwards
M'ith the right hand, the fingers bent, and the wrist or fore-arm previously
extended ; fourthly, from right to left, if with the same conditions, the left hand
is used. The direction from left to right being the most natural, is of course the
most usually followed, so that the others might strictly be ranked amongst the
exceptions, and are at least not so frequently indispensable. A single or
simple mch'ion , is that which is made in the same direction throughout, and
which can be terminated by a single stroke of the bistoury. It is nearly always
made to the right; and, by repetition and combination varied in a thousand
ways, gives rise to those complex and multiplied incisions, whose forms,
heretofore so various, are now reduced to the V, the T, the -f, the ellipse,
the oval, the crescent, and the L.
Art. 1. — Simple Incisions.
Direction. — Tn the absence of special indication, the incision should be
parallel ; first, to the greatest diameter of the part ; secondly, to the direction
of the arteries, the large veins, or the principal nerves ; thirdly, to the direc-
tion of the fleshy fibres, the muscular masses of the tendons ; fourthly, to the
natural folds of the teguments ; or, fifthly, to the great axis of the tumor.
On the dorsal and plantar surfaces, and on the sides of the foot, about the
knee, before, behind, and on the outside of the thigh, it is made in a
direction parallel to the axis of the limb, because the vessels, the nerves, the
muscles, and the tendons there have mostly that direction. Behind the
ankles it is made somewhat concave forwards, because in this part the same
organs are necessarily somewhat cui-ved in order to reach the sole of the foot;
on the inner side of the thigh it should be oblique, to correspond with the
course of the muscles of the leg, of the saphena vein, or of the femoral artery;
in the groin it is never made in the direction of the great furrow of that part,
except when they are intended to go no deeper than the subcutaneous cellular
tissue.
On the breech the muscles serve as guides, and the same is true on the
sides of abdomen, while before and behmd this cavity, the incision should
follow the axis of the body ; the chest requires the observation of the same
rules, except towards the arm -pit, where it is better to follow the axis of the
trunk than the fibres of the serratus. In the hand, reference should be had
to the wrinkles of the palm, and in the bend of the arm, to the arrangement
OPERATIVE SURGERY. 5
of the veins, muscles, or arteries, rather than to the axis of the limb. About
the neck incisions should correspond in direction with the muscles, the vessels,
or the axis of the part, as the circumstances of each case may require ; and
it is seldom or never right to cut directly across, except in the bottom of the
fossa, above the collar bone. On the cranium they should be parallel to the
muscles, or the principal arteries. About the eye-lids they should be made in a
semilunar curve, concave towards the eye, to correspond with the muscles,
the wrinkles, and the arteries: it is much the same with the lips. They
should be straight on the nose, and oblique in this or that direction upon the
other parts of the face, according to the wrinkles on which they fall, or to the
vessels or the muscles over which they are to pass. Lastly, on the ear the
projections of that organ should regulate the direction of the incision.
' The nature, the comparative depth, and the form of the disease are the only
circumstances which can justify an infringement of these rules.
Stretching the Skin. — There are several ways of fixing the skin in order to
make a simple incision.
1st. With the cubital side of the left hand, the thumb acting in the opposite
direction.
2d. By graspino; the part underneath with the whole hand.
3d. With the extremity of the four fingers placed in a line parallel to that
in which the bistoury is to pass.
4th. By taking up a fold of the integuments.
5th. Causing the tissues to be stretched by assistants in order to keep both
hands free.
6th. In drawing on one side whilst the assistant pulls the integuments
towards the other.
With the thumb and little finger the part must be accurately supported,
and the tension is seldom equal on every point, unless we use the assistance
of the index and even that of the two other fingers. To grasp the organ is a
method which can only be applied to limbs, or to certain tumors which are
verv prominent or pendulous.
With the ends of the fingers the skin is firfhly fixed, and the nails give
support to the instrument, but the tension is incomplete, and is only made on
one side. To take up a fold of the integuments is only proper in a few cases,
and is not always practicable. The hands of assistants or of one assistant are
never so safe as that of the operator himself, and should never be put in requi-
sition, except in cutting around, or on the surface of tumors, and large masses
of flesh ; the first mode is therefore the best, and it is for the surgeon to decide
under what circumstances it will be necessary to resort to either of the others.
§ 1. Incisions from Without Inwards,
To cut from without inwards, the bistoury maybe held in the first, third, or
sixth position, according to the degree of force to be emploved, the situation
of the disease, or the extent to which the incision is to be carried. The convex
bistoury which, all things being equal,cuts better and with less pain, has neverthe-
less the inconvenience of leaving, more commonly than other kinds of bistoury,
portions at the two extremities of the incision imperfectly divided, and is ill
adapted to operations somewhat delicate, which pass deeper than the skin, and
to incisions made upon excavated surfaces, and require that tlie instrument
should act principally witli the point. The straight bistoury, tliough less rapid
in the commencement of the incision, is nevertheless afterwards incomparably
O NEW ELEMENTS OF
in the commencement of the incision, is nevertheless afterwards incomparably
more convenient, and could strictly be substituted for the other in ^very case.
In the first position the convex bistoury is rested with the most prominent
point of tlie blade on the middle of the space supported by the thumb and
fore-finger, and then drawn from left to right, as far as the point where the
incision is to terminate, so as to divide the entire thickness of the skin at the
lirst sweep, and even deeper still if no important organ be situated beneath.
In order to leave as small a trace as possible imperfectly divided, care should
be taken to apply the instrument with firmness in the beginning, and to raise
the wrist in terminating the incision. Held in the third position the bistoury
will cut more with the extremity than with the prominence of the blade, and
will be less likely to wound or injure the parts beneath, or to leave long traces
at the ends of the incision, but it loses much of its lightness and of its other
advantages. In the sixth, it cuts like a razor, dividing with case the finest
:ind softest layers, as well as the thickest and most tense, but its stroke wants
firmness, and seems like cutting upon air.
The straight bistoury, held in the first position, pressed like the other, and
drawn and witlidrawn in the same manner, acts principally with the point.
Jt does not penetrate so well, but cuts more equally and leaves scarcely a
trace not fully divided. In the third position, the point should be sunk, by
puncture, to the intended depth of tlie incision, the hand being raised for
!hat purpose : in continuing the incision, the wrist should be brought down by
degrees, but again elevated at the end of the operation, so that the edge may
be at that point perpendicular to the surface cut. The whole process begins
v^itli a motion like that of a scale-beam descending-, and ends with a corre-
sponding motion upwards. In this position, the little finger, placed on the
right of the incision, serves as a support for the hand, and gives steadiness
and security to the successive stages of the operation.
Lastly, when held in the sixth position, the straight bistoury acts in the
same way as the convex when held in the same manner ; with this difference,
that it does not penetrate so t[uickly nor so well.
§ 2. Incisions from Within Outwards.
An incision of this class is sometimes made without the aid of a conductor,
at other times with ; sometimes with the bistoury, and sometimes with the
scissors ; sometimes in a part yet undivided, and sometimes through a previous
division.
WithmU the conductor, with the bistoury — without a previous division, inci-
sions are made either towards or from the operator. When the incision is
made, the instrument is held in the second position and entered by puncture,
after which the wrist is quickly raised, so that the bistoury may' divide the
tissues from its heel to the point, acting as a lever of the second kind ; or else
we raise the point by depressing the hand, so as to pierce the skin a second
time, and finish by drawing the bistoury towards the operator with the edge
upwards, so as to divide the parts between the points or the entry and exit of
the instrument, causinj^ it to move as a lever of the third class. When the
incision is made in a direction towards the operator, the instrument is held in
the fourth position, with the ring-finger fixed on the side of the blade at such
a distance from the point as properly to limit its progress. It is then entered
b}^ puncture, and wlien it has penetrated to a sufficient depth, it is rapidly
brought to a perpendicular position, acting like a lever of the second class.
OPERATIVE SURGERY.
§ 3. Upon a Director.
When there exists a previous opening, the instrument is passed through
that, either towards or from the operator, without a conductor, when this can
be easily done ; otherwise laid flat on the fore finger, or guided by a grooved
director, if the finger would occupy too much space. After this is done, the
operation is performed as mentioned above. The director is held in tlie left
hand, like a scale-beam or a lever of the first class, of which the fore-finger
placed beneath forms the fulcrum, the thumb upon the plate the power, and
the layers which the point tends to elevate the resistance. To glide along the
groove with ease, the bistoury must then be held in the second, fourth, or
sixth position, with the edge upwards. Those which have no cul de sac,
present no obstacle to the point of the instrument, which then can be passed
directly onwards until it emerge by piercing the skin ; but where there is a
cul de sac, the bistoury must be raised as a lever of the second grade. The
narrower the bistoury the more easily it advances. The convex bistoury is
not adapted to such cases, because its extremity is too lar^e, and its point,
depressed too far behind, easily comes against the groove of the director.
After having placed the director, another method maybe used; feel for the
end of that instrument through the skin, and, having ascertained the point under
which it projects, cut upon it by a slight transverse incision, so as to make a
counter opening. The point of the instrument, guided by the groove of the
conductor, is then slipped towards the handle, or^from right to left ; or even,
without making a previous incision, the point of the bistoury held in the fourth
position, may, by puncture, be brought in contact with the director near its
beak, and carried in the fourth position rapidly along the groove towards the
body of the operator.
In using the scissors you introduce one branch upon the finger, or upon a
director, leaving the other on the outside, and then cut from you as briskly as
possible all that you design to divide.
§ 4. With a Fold of the Integuments,
With timorous or refractory subjects, if the skin is very unsteady or waver-
ing, or if it is desirable not to penetrate beyond it, it is sometimes necessary
to take up a fold of it before cutting. This fold, which varies according to
the extent to which the incision is to be carried, should be held on one side
by an assistant placed in front, and on the other by the operator. It is then
divided from its free edge towards its base, as in the incision from without
inwards, or by puncture in the contrary direction ; that is, passing through
from the confined towards the free edge as in making an incision from within
outwards. The pressure made upon the integuments in folding them up,
deadens their sensibility, and consequently renders the pain less acute. Besides,
as the bistoury only pierces the parts like an arrow, there is no risk of failure
or embarrassment from the movements of the patient. The objection to this
mode of practising incisions is, that there is rather less certainty of giving
exactly the suitable extent than in those above described.
§ 5. Horizontally,
The horizontal incision is that which is most rarely practised, and only when it
16 desirable to cut out successively over some one point the various laminae
NEW ELEMENTS OF
concealing an organ, which is to be avoided. The bistoury is then held in tlie
sixth position, with the edge on one side; the left hand armed with fine pincers,
lifts up successive layers of tissue, while the right hand shaves oft' the portions
thus raised with the bistoury held horizontally below the beak of the forceps.
This kind of incision is almost exclusively reserved for herniotomy, but is
yet occasionally used in some other operations, such as those for aneurism.
Art. 2. — Compound Incisions,
Complex incisions, being but a combination of simple ones, are necessarily
subject to the same rules of practice, and may in the same manner be executed,
from without inwards, or from within outwards, and with or without a director.
1. The V incision is composed of two straight incisions, which, starting
from the same point, terminate at a greater or less distance apart, according
tc the extent of the triangular space which is to be included between them.
The angle should, in the absence of particular counter-indications, be turned
towards the lowest part, and the incisions should be made towards and not
from that point. The reason of this rule, which at the first glance seems
inconsistent with the aim proposed, is, notwithstanding, easily comprehended.
If the bistoury were applied to the extremity of the first incision, in order to
execute the second, it would press upon or weigh down the edge now deprived
of support before it could cut, occasioning more pain than is necessary, and
producing a contused and irregular incision. If the convex bistoury were
used, there would be the additional inconvenience of making a scratch beyond
the external border of the first incision, or leaving the second imperfect near
the angle. In beginning at the base of the triangle, no inconvenience of this
kind will be sustained. The skin maybe as easily held tense tor the second
incision, as for tlwi fii'st. Tiie bistoury itself stretches it in some measui e in
approachin;^ the apex of the triangle, which it isolates and completes without
difficulty, if the surgeon take the precaution of raising the wrist in finishing.
To detach the flap of integuments, which has been limited by such an incision,,
it must be seized at the point with the pincers, for which it is well to sub-
stitute the fore-finger and thumb, as soon as it is practicable. The right hand
provided with the straight or convex bistoury (no matter which), is held in
the third position when you intend to cut towards yourself, or by bending the
fingers; in the fifth position, on the contrary, if you intend to cut from youy
or by the extension of the fingers ; dissect up the flap by free sweeps from
below upwards, or from the apex to the base, taking care to raise with ita
layer of cellular tissue as thick as possible. Formerly the V incision was
thought indispensable in the operation of trepanning the temple ; at the present
day it is absolutely required nowhere, but is occasionally wsed in the removal
of certain tumors, and in certain disarticulations.
2. The oval incision, which will be discussed under the article of Ampu-
tations, differs from the incision V in this, that it continues from one branch
of that incision to the other, passing round the base of the flap, which is thus
completely isolated.
3. The cross incision consists, as its name indicates, of two simple incision»
which cross each other at right angles. Only the second of these incisions,
needs to be described. It is commenced at the left side of the first division
-with the same precautions as in all other straight incisions ; but, instead of
being carried across without interruption, it is terminated with an elevation of
the wrist at the point where it touches the first incision, of which it cuts only
the left lip. To complete it the operator changes the position of the bistoury^
OPERATIVE SURGERY. if
unless he prefers to take it in the other hand, and repeats on the right the
operation which he has just performed on the left. In short, it is an incision
made in two separate steps, of which the two portions, having a common
termination, meet in the middle of the first incision ; and which does not allow
the instrument to roll or fold under its edge the second lip of the first incision,
as it would almost inevitably do in passing from the left to the right, so as to
complete the incision at a single stroke.
The dissection of the four triangles which result from this double division,
is but a repetition of that which has been already mentioned in speaking of
the V incision.
4. The T incision difters from the crucial incision in but one point, that is,
instead of passing on both sides the second incision stops upon the first,
forming with it only two right angles ; so that it consists of two cuts, instead
of the three, which form the crucial incision. For the rest, the same precautions
are to be taken in the division of the tissues and in the dissection of the
flaps, and the manner of holding the bistoury is the same in both cases.
The crucial incision, and the T incision, being mere modifications of each
other, are indicated whenever a straight incision is insufficient to expose
the tissues which it is intended to isolate or remove. The relative value of
either should be determined by the size of the part to be exposed.
The bistoury, carried flat between the integuments and the tissues beneath,
and there turned so as to cut from within outwards, or otherwise, conducted
along the groove of a director, would convert a simple straight incision into a
complex one, as securely as if it were directed upon the skin cutting from
without inwards. This method is indeed sometimes preferred.
The elliptical incision, which becomes in almost every case necessary in
the operation on a subcutaneous tumor where it is thought proper to remove
a portion of the integuments, is formed by the union of two curved incisions,
with the concavity of each presented, towards the othei*. To trace out the
direction with ink has no other inconvenience than that of being useless,
except in certain rare cases, where, by the least deviation of the bistouj^,
great hazard would be incurred. This is a case where the hand of an
assistant is of advantage to hold the skin on one side, whilst the surgeoa
stretches it upon the other. The rule demands that the lower incision should
be first made, so. that the bleeding which might be occasioned by the operatioa^
should not interfere with the performance of the other. It is made by
cutting from left to right, or towards the operator, while the assistant raises-
the tumor, and the operator stretches with the left hand the integuments
beneath. This arrangement is reversed in making the second incision ; for
here the surgeon himself usually draws towards him or depresses with the
ends of his fingers the mass to be excised, while the assistant stretches the
skin above, taking care at the same time that this tension is exerted at one
time in a transverse and at others in a longitudinal direction, in such a manner
that the instrument, carried to the left extremity, or to the upper part of the
inferior incision, can make the incision as neatly in the beginning as in the
middle of its progress, and will have no folds of skin rolling before it towards
the end.. It should not be forgotten, moreover^ tliat this upper incision being^
carried above a depressed part, needs but a slight degree of curvature during,
the passage of the knife to become deeply concave immediately afterwards,
when the parts are left to assume their natural posltioui
Crescentic incision, — Some persons have thought of late, that a double
curved incision, with both parts convex in the same direction,, could be, in
2
10 NEW ELEMENTS OF
certain cases, advantageously substituted for an elliptical incision. The
crescentic portion which it circumscribes, leaves a wound with a loss of
substance, the convex edge of which may be dissected and turned over on
its base, so that it can be afterwards applied to the concavity of the other
edge, and over the bottom of the hollow left by the operation. Might it not
be adopted for the extirpation of extensive tumors where it is possible to
preserve nearly all the skin, and where a straight incision would not suffi-
ciently expose the disease? It would afford the same advantages as an
elliptical incision, without opposing so strongly an immediate reunion. —
The dissection of the flap described by a simple semilunar incision, where
no skin is to be removed, may be performed in the manner above described
under the T, the V, and the crucial incisions, for which this is frequently
substituted. In conclusion, I will add, that by dissecting up the lips of any
incision whatever, from the subjacent parts to the extent of an inch or more,
according to the wants or situation of the wound, you are often able to cover
extensive losses of substances, since the integuments thus raised may be
stretched to an astonishing extent, and permit us to bring into contact the
borders of an assemblage of wounds which would have been thought incapable
of meeting.
The L incision, which is used in exposing some large arteries, as the
carotid and subclavian, need not be here described.
Art. 3. — Incisions applied to Abscess — to Collections of Fluids.
It may be boldly asserted that the bistoury is the sovereign remedy for
abscesses, whether hot or cold, diffused or circumscribed, vast or incon-
siderable. The pain which it produces is nothing in comparison to the acci-
dents which it prevents ; and I can scarcely comprehend why it is that
its use is so often abstained from, merely because fluctuation continues
obscure in the sequel of phlegmonous inflammations. Since it is a very
eflfective means in the treatment of subcutaneous inflammations themselves,
suppose even that the sac is not opened, what evil can result from its
application ? It is a perfectly simple wound, winch relieves engorgements,
and presents no obstacle to the disappearance of the original malady ; but, on
the contrary, favors, in almost every case, its progress towards recovery.
After having witnessed the ravages secretly committed by the presence of
pus, either infiltrated or effused into the organs by the absorption of this fluid,
or by its migrations through long tracts of cellular tissue, it is impossible to
hesitate between such dangers and the fear of making a useless incision.
Every kind of straight incision is applicable to abscess, the further treatment
of which I shall not here discuss. The large abscess lancet, which was
formerly thought so indispensable, has entirely fallen into disuse for this half
century past. The common lancet, which sometimes takes its place, is
insufficient, except for a very few cases ; as where the skin is very thin, and
the abscess very superficial or small ; and even then the bistoury should be
preferred, if there were not certain beings occasionally to be found who are
terrified at the very name of ** bistoury," but who would submit without
reluctance to the stab of a lancet.
§ 1. Incision from Within Outwards.
There is no circumscribed abscess which cannot be opened from within
outwards. The operation is rapid, and gives but little pain ; the instrument
OPERATIVE SURGERY. 11
penetrates by puncture ; its point plays in the interior of the sac, and its edge
being raised so as to cut from heel to point, stretches the cutaneous covering
as fast as it divides it, instead of pressing it down. In a case of this kind,
the straight bistoury is the only one that should be used. It is never held in
the fifth position, except to cut from you at the bottom of some cavity, as for
instance, in certain abscesses in the hollow of the cheek. But it is very
frequently used in the second position. When it is thus held, it affords all
necessary force and ease ; it penetrates with great facility in a direction from
the operator with any degree of obliquity that may be. desired, and nothing is
more simple than to sway it as a lever of the second class, by raising the wrist
at the proper moment for terminating the incision. The fourth position is
still more convenient; the support which is given to the hand by means of
the ring and little fingers, is an advantage which the second does not
present in the same degree. The puncture is made towards the surgeon with
the hand and fingers flexed ; it is only necessary to extend these at the same
time that the handle of the bistoury is drawn back to assimilate it to a lever
of the second class, as, in the previous case, to make the incision from heel to
point, and to divide the outer wall of the abscess through its whole extent
with equal firmness and celerity. This is the position which incurs the least
risk from inconsiderate movements or refractory behavior in the patient, and I
have been long in the habit of using this in preference to the others, where
there was no special indication to the contrary. The puncture being made,
the remainder of the incision takes place almost spontaneously. Upon occa-
sion, this position will be as convenient as the second for transpiercing through
and through a hard or superficial sac, as it is sometimes proper to do in cases
of furunculus or anthrax, and of some prominent abscesses on the limbs,
covered by an extenuated portion of skin. The best bistoury in such a
case, and indeed generally for opening abscesses from within outwards, is
one'with a narrow blade accurately grooved and perfectly keen. It is held
more or less obliquely, according as the deeper wall of the abscess is more or
less distant from the surface ; if this were touched, and cut with the point of
the instrument, the inconvenience, in ordinary cases, would scarcely merit
attention ; but the danger would be so great, when the abscess lies before
one of the larger arteries or an important viscus, that the mere idea of such an
accident is dreadful. It is a precaution, then, of prudence, if not of necessity,
at once, as soon as the cessation of resistance or any other circumstance gives
notice that the instrument has entered the cavity of the abscess, to turn it into
a position more nearly parallel to the axis of the limb or of the diseased part,
and to prolong the incision only by raising and withdrawing the bistoury.
In practising this mode of incision, the stretching of the parts with the left
hand, whilst the right hand operates with the bistoury, although useful is not
always necessary. If the collection is large, superficial, or situated at a great
distance from any delicate part, you may even dispense with the support of
the fingers, and depend solely upon the movements of the hand, as if you were
swaying it in the air. After a little practice in the use of the instruments, one
of the fingers detached from the others, and placed upon the side of the blade,
secures you against the danger of pushing the point of the bistoury to too
great a depth, and takes the place, in the greater number of cases, of every
other precaution.
12 NEW ELEMENTS OF
§ 2. Incision from Without Inwards.
The diffused abscess, the deep abscess, and those which develop themselves
around the articulations, upon the passage of vessels, and upon the surface of
organs, which it would be dangerous to touch or pierce, usually require that
the opening should be made from without inwards. The first require large
incisions, either with the straight bistoury in the first or in the third position,
or the convex bistoury held in the same manner. With the straight bistoury
in the first position, the incision is made by applying the whole length of the
edge upon the skin, as for deep scarifications, and it is drawn backwards, and
at the same time pressed so as to cut rapidly from heel to point. In the third
position the point is at first plunged directly into the sac, and the incision is
then continued by bringing down the heel and the rest of the edge, the point
remaining stationary. The bistoury becomes thus a lever of the second class,
but working from above after the manner of a straw-cutter. With the convex
bistoury, held in the first position, you cut quick and deep; it suits generally
better than any other such a purpose as this, and is particularly well adapted
by its form to cases in which it is necessary to make several incisions at some
distance apart, over the surface of a purulent collection. The second class of
abscesses divides itself naturally into two orders: — 1st. Those which are
covered over with a thick and dense layer, and do not lie upon any organ
which it is important to avoid. 2dly. Those which lie so deep that their
precise seat cannot be ascertained, or which it is not prudent to expose at a
single stroke. There is no objection to attacking the first kind by puncture
and a depression of the handle, using the straight bistoury held in the third
position ; for example, on the eminences of the hand, on the pahnar surface
of the fingers, on the external sides of the limbs, on the breech, on the cranium,
and in the posterior region of the trunk.
The incision by puncture is not applicable to the second class of abscesses.
If these are to be opened with the straight bistoury, it must be drawn with
the edge towards the abscess in the first or third position, and divide, by
successive strokes, the parts which conceal the matter, while the fore-fingei*
of the left hand is, from time to time, applied to the bottom of the wound to
ascertain the fluctuation or the probable depth of the abscess. This is the
proper mode of operating for abscesses formed under aponeuroses, between
the crural muscles and the thigh-bone, in the hollow of the ham, about the
humerus, in the thickness of the abdominal parietes, or of the muscular
covering of the chest, or on the forepart of the neck.
Unless we proceed with the same caution in the neighborhood of the joints,
we shall run the risk of opening the subjacent capsules and the synovial
membrane, and of exposing bony surfaces to the air, whilst these incisions,
made through successive layers, do not prevent you from entering the capsule
at last, where this is deemed indispensable. If the abscess is extensive, and
its external wall sufficiently extenuated, the convex bistoury is preferable,
because it makes a cleaner incision, and gives less pain. When its seat is
less clearly indicated, we have recourse to the straight bistoury, which is
better adapted to the more delicate operations.
The same principles will guide us in cutting about an artery, an aneurism, or
a hernia, near the pleura or the peritoneum; because then tlie operator is sure
that he shall not pass the interior wall of the sac before meetin«5 with the pus,
and that he may interrupt the operation when he chooses, to feel the pulsations
of arteries, and to ascertain with the finger upon what tissue he is working:
OPERATIVE SURGERY. IS
whereas in operation by puncture, there is nothing to guarantee the safety
of the concealed organ when once the bistoury has begun its progress.
How many times has the instrument been plunged, in opening an abscess, into
an aneurism, or a large healthy artery, or a hernia, and that too by celebrated
practitioners, simply for want'^of paying proper attention to these indications !
One of the principal faults to be found with incisions from without inwards
is that of pressing upon the abscess in opening it. It is no sooner opened
for some few lines, than this pressure forces out the pus, lessens the tension
of the partitions, and renders it almost impossible to continue the incision at
the same stroke; this, however, should only be understood of slow or
gradual incisions. Those which can be made briskly with the whole edge of
a straight bistoury, or what is better, of a convex bistoury held in the first or
sixth position (as"^in collections of great extent, situated immediately beneath
the skin), have not the same inconvenience, and are in fact the least painful
of all.
With a Director. — To enlarge the opening of an abscess, the finger or the
grooved director serves as a guide to the instrument, and the bistoury or the
scissors are directed in the manner already laid down in speaking generally
of incisions from within outwards, with the aid of a director and a previous
opening.
§ 3. Complex Incisions.
The same rules will govern the operator if, instead of a simple incision, he
wishes to open an abscess by an incision in the shape of a V, a T, or a cross.
Modifications like these, which are more frequently useful than the greater
part of practitioners seem to admit, are of very great advantage in cases of
subcutaneous collections with alteration of the skin. The first opening being
made upw^ards, and to the left for instance, the director finds itself a passage
under the skin to the right ; a second incision is then made in the latter
direction, and the abscess, laid open, presents a V incision. When the cul de
sac is on one side, an incision in T is made, and in collections where it is
desirable to lay the bottom entirely open, the crucial incision finds a place.
Thus we see that, except elliptical or semicircular incisions, every description
of division can be called in in the treatment of purulent collections, but yet
that the simple incision is almost uniformly the only one required.
Art, 4. — Incisions applied to the Dissection of Tumors and of Subcutaneous
Cysts*
In the excision of cysts and tumors, contrary to what has just been said of
the treatment of abscess, the complex excision is most commonly indicated.
When the whole of the skin should be preserved however, a simple incision
will often suffice. Vascillating or very movable tumors covered with sound
and flexible skin, do not always require a complex incision. The testicle,
the breast, and several degenerate ganglia, are often extracted by a simple
straight incision, although they may have acquired a very considerable size.
§ 1. Form of the Incision.
1st. The straight incision should pass from a half-inch to an inch, or even
more than that, beyond the limits of the tumor at either end, and penetrate
14 NEW ELEMENTS OF
the entire thickness of the adipose layer. There are then several methods
of continuing the operation. One of those most frequently adopted is, to
seize with the forceps or the first fingers of the left hand, each of the lips of
the wound, and to dissect them, one after the other, from the wound outwards,
with tlie rio-ht hand, whilst an assistant draws the tumor in the opposite
direction, with his fingers, a crotchet, or a hook. Others prefer, where the parts
are sufficiently loose and flexible, to press with the thumb and fingers of
one hand through the skin, upon the sides of the body to be extirpated, as
deeply as possible, as if to expel it through the wound, whilst with the other
hand, the adhesions of the cellular tissue are cut perpendicularly, in proportion
as the borders of the incision separate or withdraw themselves backwards. If
the tumor is pendulous you attain the same end by grasping it below with the
whole palm or the hand. By this method the pain is generally less, the operation
at once prompt, easy, and sure, but unfortunately is not in every case appli-
cable. Some find it more convenient to hold the tumor themselves, and to
cause the lips of the incision to be drawn back by an assistant, whilst they
dissect and detach it from its bed. Indeed this is the best way to operate in
almost every case as soon as its anterior face has been exposed. In adopting any
other course for the purpose of separating it from the deeper tissues, the surgeon
exposes himself to the danger of penetrating too far, or else of not removing
all the diseased parts. He can in this point of view rely only upon the
testimony of the fingers, which have however the inestimable adivantage of
being able to feel arterial pulsations if they present themselves, and to confine
their movements without difficulty as well as to adapt them to the action of
the other hand.
2d. V Incision. — It is an erroneous idea that the elliptical and crescentic
incisions are the only ones which permit the actual abstraction of substance
from the integumenti The V incision has more than once fulfilled the same
indication. By cutting several Vs or triangular flaps, continuous at their
bases upon the surface of voluminous tumors, there may be raised with the
diseased mass a star of integuments, which does not afterwards hinder the
covering of all the bloody surface with the remaining triangular portions.
M. Delpech and M. Clot, have had recourse to a similar device in the extirpation
of elephantiastic tumors, of which they have given the first notices, and I have
seen M. Roux operate in this way for the removal of a fungous hematodes from
before the knee.
3d. The T incision or a crucial incision, is only used where the skin, of
which it is not desirable to remove any part, is not flexible enough to allow a
straight incision properly to expose the tumor. It is also indicated in certain
cases, conjointly with the elliptical or crescentic incision 5 for example, when
the base of a cyst extends so far beyond the flap of integuments which has
just been circumscribed that it appears difficult to raise alternately the lips
of the wound, or where it is desirable that the flaps should not be very large.
In this case all that is to be done is to divide transversely one of the ed^es of
the ellipse or crescent for the T incision, or both of them successively tor the
cross.
§2. Dissection of the Flaps,
Whatever may be the then form or extent, these different incisions give
rise to flaps which it is necessary to raise from the apex to the base. This
is usually the most delicate part of the operation, and is not executed by
precisely the same rules for tne exposure of all kinds of tumors.
OPERATIVE SURGERY. 15
1. Concrete Tumors. — Whenever it is necessary to operate for the removal
of adipose tumor, or any other solid mass free from malignity, the edge of the
bistoury should be more inclined towards the tumor, or the deep parts, than
towards the skin, since the thicker the flap is left by raising with it the cellular or
adipose mass which lines it internally, the more life it retains and the more it
is disposed to attach itself to the layers beneath. If inclined in the opposite
direction, the instrument would leave the skin entirely naked, might even
pierce it, and render its preservation or restoration impossible, while even,
if we should proceed too far inwards, I cannot see what evil could arise
from it.
2. Cancers. — Carcinomatous tumors deserve a little more attention. Tlie
skin should not, indeed, be denuded, but it is necessary at the same time
to avoid turning over with it the least trace of the morbid tissue.
S. Cysts. — The removal of encysted tumors, of sacs filled with matter
wholly or only partially liquid, which it is desirable to remove without opening
them, require still more care ; the sides of the cyst are sometimes so thin
that the least pressure with the edge of the bistoury divides them ', the bag
is quickly emptied, and the tissues can no longer be held tense; the operation
which, without this accident, would have been one of the most easy and
simple, becomes immediately most laborious, and even in some instances
insusceptible of completion. It is necessary then, although we endeavor to
preserve the cellular tissue in exposing a cyst, to turn the edge of the instru-
ment a little more towards the integuments than in the direction of tiie
tumor, whenever the parietes of the cyst are superficial enough, or appear
thin enough to be easily pierced.
For the rest it is well to remark, that certain cysts do not require so
much caution, and that the operation may be confined to cutting through
the whole anterior wall by a simple incision, by a T, or by a crucial incision,
as in the case of abscess. To this class belong deep and adherent hydated
tumors, or those of which it is desirable either to cauterise the interior of the
cavity or to expose it to the air, in order to occasion suppuration. We shall
see hereafter that the same may be said of the encysted tumors of the cranium
and some others.
4. Abdominal cysts, and collections of liquids which border upon the
great cavities of the trunk, and the adherence of which to the serous membrane
of the walls of those cavities is not fully ascertained, often justify a mode of
incision mucli boasted of by some practitioners in modern tijnes. It is a
simple incision, straight or curved, carried through, layer after layer, by
successive strokes with a straight bistoury held in the first or second posiiion
with the edge towards the cavity. If the cyst is in the abdomen, the mcision
is carried by degrees as far as the peritoneum, which is opened over the tumor
if it is found not to be adherent, and which is left untouched if it appears to
be incorporated with the parietes of the morbid sac, and these very much
extenuated.
The operation here terminates for the time, the seton-cord is placed length-
wise in the wound, so as to keep the lips separate, and is renewed as often as
may be necessary for a certain number of days. Constrained by the pressure
of the divided tissues, the cyst inclines to slip between the lips of the incision,
approaches the exterior, and often finishes by bursting, or by opening spon-
taneously, sometimes the next day, but more frequently at the expiration of
several days.
If it was unattached, this incision would occasion an adhesive inflammation,
which would immediately unite the anterior partition to the laminae which
16 NEW ELEMENTS OF
cover it ; puncture or incision could then be practised without the least danger
of an eftusion into the abdomen.
Art» 5. — To cause the least possible Pain,
not at
surgery, are
To avoid giving pain in making incisions, is a chimera which is
this time pursued by any one. Cutting and pain, in operative surge ^
two words which always suggest each other in the mind of the invalid, and the
association of which it is always necessary and proper to recognize. The efforts
of the surgeon should then be confined to rendering the pain of the incision
as light as possible, without endangering in any degree the success of his
operations.
The pretensions of several foreign writers, German surgeons among others,
and of the editors of the work of Sabatier, who think that they have attained
this end by never using the bistoury without having first dipped it in oil, seem
to me entirely without foundation. By attaching itself to the pores of the
bleeding surface, the oil would even have the ill effect of impeding the circu-
lation of the fluids, the exudation of the plastic lymph, and the cohesion of
the sides of the wound, if it is intended to eftect this by primary inosculation;
a cerate which could be removed by washing would be more suitable if any fatty
substance whatever could be of use. It cannot be denied, that after being
held for a moment in warm water, as is advised by M. Richerand, or in any
other way kept at the temperature of the body, according to the opinions of M.
J. Guyot, the operation of the instrument can be supported with less pain to the
patient, but upon a close examination the difference is not very strongly marked ;
the precaution would cause too much embarrassment for it to be adopted in
practice, or to be accorded any great degree of importance. It is first to the
hand of the operator, and next to the qualities of the bistoury, and not to such
accessory circumstances, that we are to look for the remedy desired.
Have a light and sure hand, a bistoury with a fine and keen edge, give your
incision at the first stroke all the length and depth which it ought to have, if
you can do so without danger ; act promptly and without hesitation ; give to
the wound an extent rather too great than too small, yet without unnecessarily
prolonging it, and you will have to regret or to apprehend no other pain
than that which is inherent in the operation, and which no human contrivance
can detach from it. Any further details on this subject would be entirely
superfluous.
SECTION III.
Punctures.
Whenever the surgeon thrusts the point of the instrument through any
of the tissues, he makes a puncture. Those from within outwards are almost
always made with the bistoury, the suture needle, or with spring instruments.
Those which pass inwards from without are made sometimes with the straight
bistoury or the lancet, as we have seen above, sometimes with the needle or
other particular instrument, a trocar, &c.: with a round straight needle, in
certain sutures, provided with an eye at the blunt end similar to ordinary
sewing needles: with a needle longer than the other, and provided with a
head, a handle, or a ring, such as that used for acupuncture: with a needle
cutting at the point on one or both sides, straight or curved, for the purpose of
exploring certain tumors, or collections of a doubtful character, as has been
recommended by many practitioners after Dr. Hey : with a needle curved
OPERATIVE SURGERY. 17
in the arc of a circle, edged, andprovided with an eye to carry the thread used
in most kinds of suture : with the different kinds of trocar, when a canul^
is to be introduced into tlie bosom of some reservoir or cyst, in order to
extract the fluid, without leaving any considerable wound to cicatrize.
1. By acupuncture is understood a puncture which traverses the tissues
without breaking the continuity of their fibres. The needle which is used
for this operation should be a regular cone. The surgeon pushes it in, rolling
it at the same time between the fingers of one hand, which hold it like a pen
and press it gently upon the skin, which is stretched by the other hand : thus
conducted, its point removes from its track, but does not divide the organic
fibres ; can traverse the arteries, the heart itself, the most essential organs,
without occasioning the effusion of any liquid, and without leaving the least
trace of its passage. In China and in Egypt where acupuncturation has been
known and practised from time immemorial, and with great success, thej
frequently strike with a little mallet on the extremity of the needle as it is
held in the left hand, to cause it to enter, instead of rolling it between the
fingers of the right hand. Entering it more rapidly by a simple effort of
pressure, as is practised by some persons amongst us, generally causes some-
what more pain than is necessary, and prudence will not allow us, on the
principles here laid down, to pass it through any great vascular canal.
2. The needle assigned to ordinary punctures is more easy to conduct, and
should not be so slender. Although the round needle has been recommended
for opening a gaseous collection in a strangulated portion of intestine, the
needle, shaped like the head of a lance, with the point straight or curved, is
almost always used for the purpose of exploring. A tumor presents itself in
a complex region of the body 5 you are not certain that it contains a liquid, or
if it does, whether this liquid is of blood, pus, or serum ; whether it is an
abscess, a cyst or aneurism. The puncture with an appropriate needle at
once dissipates these doubts. If there is any fluid at the bottom of the mass,
it allows some drops to ooze out and affords an opportunity to determine its
nature. The small wound which is produced is immediately closed, even in
the case of arterial cyst. The surgeon then takes his course with a full-
knowledge of the case.
3. The use of the trocar is distinguished principally from that of the
needle, by the canula which the instrument carries with it, and which
becomes the conducting tube for the fluids which are intended to escape. Its
point should be flattened like that of a lancet, or pyramidal with three cutting
edges, and as it is generally blunt it requires some force to make it penetrate;
hence the necessity of grasping the trocar with the whole hand. The
handle is placed between the thenar and hypothenar eminences, or between the
hollow of the palm and the last two fingers flexed. The thumb and the
middle finger a little farther advanced, hold it near the root, whilst the fore-
finger extended sustains the body of the instrument near the point, in order
to limit the depth to which it should penetrate. In case of necessity, we
might for greater safety detach the middle finger from the instrument, and
rest it on the side of the point to be pierced. When it is entered, the fore-
finger and thumb of the left hand hold the canula with the point of the cup
downwards, whilst the right hand pulls by the handle and raises the perfo-
rating shaft. The sac is emptied, and the liquid contents received in a
vessel. In order to withdraw the tube it is only necessary to draw it quickly
by the head, whilst the fingers which, until then had sustained it, are applied
to the sides of the puncture, so as to retain in its position the skin or the outer
wall of the cavity.
3
18 NEW ELEMENTS OF
CHAPTER IL
REUNION.
The reunion of the divided parts is effected by the position of the patient
or of the wound, and by means of bandages, of plasters, and particularly of
suture.
Art. 1. — Suture.
The bringing together the lips of a wound with the assistance of threads
or of metallic wires, is the only one amongst the various means used in
eflfectin^ reunion which deserves the title of a bloody operation, and the only
one which it is necessary at present to examine.- The suture, which is
evidently borrowed from the art of the tailor, formerly enjoyed more favor
than can be easily conceived at the present day, from an examination of the
practice of the greater number of operators. Since the time of Pibrac^ who
80 heartily condemned the practice, and who, in a memoir, at best by no
means conclusive, endeavored almost entirely to banish it from the domain of
surgery, the suture has continually lost ground in the estimation of prac-
titioners; so that now it is no longer actually recommended in classical
works, except in a very limited number of cases. On both sides, as usual,
the bounds of truth have been transgressed. If the suture does not merit
the praises formerly lavished upon it, as little does it deserve the neglect into
which it ,has lately fallen. The only well-founded reproaches which can be
advanced against it, are, that it prevents the due escape of fluids, increases
the pain and the inflammation, and prolongs the operation. But the first of
these objections lies against the immediate reunion, rather than against the
suture; and it needs only to have witnessed what occurs in cases of hare-lip,
staphyloraphy, rhynoplasm, genoplasm, cheiloplasm, and enter or aphy, to be
convinced that tlie second and third objections have been at least much
exaggerated. In these kinds of reunion, it is not the pain nor the inflammation
which occasion failure ; and the operator would be fortunate indeed, if,
in a like case, he had to contend with no other difllculties than these. As
to the greater duration of the operation, who will venture to lay great stress
upon tliis, if the suture really possess the advantages accorded to it before
the time of Pibrac and Louis ? In justice it must be said, that it is not
actually dangerous, as has been contended by the old academy of surgery,
but yet that it is most frequently useless, and at most but seldom indispen-
sable. It can only be indicated in wounds where the immediate reunion of
the parts is desired ; and even in this kind of lesion there are many cases in
which it might be omitted without injury. While we count it better than any
kind of bandage or plaster that can be contrived, where it is necessary to
bring into apposition the edges of large flaps of integuments, movable or ill-
supported, or of membranous or very thin organs, it would be but a feeble
resource in wounds of which the lips are firm and loaded with cellular tissue,
which penetrate to the great muscles of the limbs, or of the trunk, and of
vhich the sides are perpetually swayed by the movements of the parts beneath.
OPERATIVE SURGERY. 19
When the suture is used, no pressure is required ; the wound can be gently
dressed without any dragging of the surrounding skin ; and the apposition,
which incurs no risk of beinff deranged, extends through the whole thickness
of the bleeding edges. In the use of strips or bandages, the skin is more or
less irritated ; the contact is rarely perfect, and if the skin be in the least
degree soft or loose, the lips of the wound continually tend to roll inwards,
and only touch by the part of their thickness next the epidermis. The least
effort, the least imprudence, causes a separation. Besides, this mode of
effecting a reunion is not applicable to every region of the body; we do not
gee that it is much more difficult to relax or to cut a stitch than an emplastic
strap or a piece of linen, if strangulation should occur.
Without reposing in this method as much confidence as is conceded to it by
Delpech, Gensoul, and most of the surgeons of Marseilles, Brest, and Toulon,
and the principal cities of the south, an abstract of whose views has been
given by M. Serre, of Montpeliers, in his treatise on '* immediate union,"
I am inclined to coincide with him, as also with MM. Dupuytren, Roux, and
Lisfranc, in the opinion that it is worthy of resuming a more prominent place
in the practice of surgery.
Of all the kinds of suture which have been devised, the science has only
preserved, and in fact, only should preserve the interrupted suture (by separate
stitches), the "seamed," or that of the glover, the *' zig-zag suture," the
suture of Le Dran, the " twisted," and the "quilled" suture.
§ 1. Interrupted Suture.
To eff*ect a suture by separate stitches, it is necessary to provide as many
pieces of thread, single, double, triple, or quadruple, as you may intend to
make stitches ; taking care that they are well waxed ; next, a sufficient number
of needles. The needles which were used in the last century, curved and
flattened only in the anterior half of their length, straight, round, or slightly
depressed laterally, and pierced in the same direction, with an extended eye,
are now entirely abandoned. The needles universally preferred, are regularly
curved in the arc of a circle 5 of equal width and thickness from one end to
the other, except within a few lines of the point; provided with a square
opening in the posterior extremity made in the direction of the thickness.
It is only necessary to place a needle at each extremity of the thread,
when the stitch is to be made by piercing first one and then the other of the
lips of the wound from its internal or cellular side towards the surface, other-
wise one needle suffices for each ligature. All other things being equal, it is
best to pierce one of the edges of the wound from without inwards, and the other
from within outwards ; the operation is more prompt and less painful, draws
skin less from the exterior to the interior than in the other direction, and does
not involve the embarrassment of changing the needle nor the hand, in passing
from one edge of the wound to the other. The right or upper lip of the wound
is that with which it is most convenient to begin. The surgeon pinches it
with the thumb of the left hand on the internal face, and the fore -finger prone
upon the external face, raising it and turning it a little outwards, he seizes
the needle already threaded with the right hand, holding it like a pen, the
thumb in the concavity, the fore and middle finger, sometimes, if the needle
be large, even the ring finger, upon its convex part, so as to turn it into a,
lever of the third class, applies the point to the skin at three or four lines
distance from the edge, pushes it by a circular movement so as to make it
come out by the wound where the thumb indicates its direction and passage,
leaves the heel as soon as it is sufficiently advanced, seizes the point with the
£0 NEW ELEMENTS OF
thumb on its convexity, continues itsprogress, and brings it out by turning the
hand towards a supine posture. Taking it then, as at first, he proceeds
immediately to the second step of the operation, which is the same with the
first, except that the needle ought to pierce the second lip of the wound by
commencing on its inner surface, and that the thumb should be used instead
of the fore-finger to support the skin. The remaining stitches are only repe-
titions of the first ; and, when several are to be made, the operation is usually
begun at the right or inferior extremity.
If any reason exist for following the old method of placing a needle at each
end of the ligature, the right or upper border of the wound, bold as above
directed, should be first pierced from its adherent surface outwards, the hand
being at first supine with the thumb on the concave side of the needle, which
is pushed in with a movement towards pronation. The perforation of the
other edge is made with the second needle just as in the former method.
To close the operation then, the surgeon dries the part or causes it to be
dried, seizes successively each ligature by its two extremities, adjusts the
co-aptation of the parts, and ties the threads one after the other at the lower side
of the wound. The practice of laying lint between the knot and the wound
so that the ligature shall not lie immediately upon the skin, although it has
been recommended by many persons, can only be justified in cases where it
is necessary to relax the suture within one or two days after its application.
In every other case the ligature should rest upon the skin, without any thing
to intervene. A pledget of lint, or charpie, spread with simple cerate, then
some dry lint, and one or two turns of a roller applied over all, will serve to
support them, where it is not thought sufficient to cover the parts with simple
compresses saturated with cold water, or even to leave them exposed to the
open air.
If nothing particular occurs, the thread is not to be withdrawn until about
the third, fourth, or perhaps the fifth day, in order to which the lower extre-
mity of the exposed part of the ligature is cut with the scissors. The surgeon
then takes hold of the knot or superior extremity with the right hand, and
removes the ligatures gently one after the other, whilst with the fingers of the
left liand he keeps in place the skin and the corresponding lip of the wound.
§ 2. Suture of Le Dran.
Le Dran conceived the idea that, especially in enteroraphy, after having
passed the threads with a straight needle, as in the interrupted suture, it
would be advantageous to unite the extremities of all the ligatures in a single
cord, and to retain them, thus collected, upon the exterior without a knot.
His object was, to be enabled to leave them in longer, and to withdraw them
separately witliout the necessity of cutting any thing. The fault of the process
of Le Dran is, that a wrinkling or plaiting of the membranes is produced by
4U*awing tlie ligatures together on each side into a single cord. The suggestion,
tlfccrefore, is not available, except in cases where a single ligature will suffice,
or when, if several have been passed, the extremities can be retained on the
a;^terior separately, as is now done in some intestinal sutures.
* Continuous Suture (seamed).
The suture, properly called the furrier's, not Pelletier's,* as it has been
• The mistake has arisen from the correspondence of the above eminent name with the
French word for glover, or furrier.
OPERATIVE SURGERY. 21
written in several modern books, in which the authors have taken, not the
name of a port, like the ape in tlie fable, but that of a trade for the name of a
man, is that which is usually employed after the opening of dead bodies, and
in veterinary surgery. Although formerly as often used in the practice of
human surgery, it is now almost entirely excluded, but, I think, very impro-
perly. Wounds that are somewhat long, or such as involve hollow organs,
are as advantageously treated with this suture in the living body as in the
dead ; and the strangulation, which it is charged with causing so easily, is •
with so little propriety urged as a motive for rejecting it, that this is, in fact,
less frequently followed by that accident than the other kinds of suture.
The seamed suture is so well known in the furrier's and tailor's arts, that
its very name is equivalent to a description. It is commenced like the
interrupted suture, except that a straight needle is more convenient than one
which is curved, and that instead of piercing the lips of the wound, one after
the other, you endeavor to bring them together, and take them up in the same
fold, so as to penetrate them both at the same stroke. An assistant then
draws and stretches out the two extremities of this fold ; the operator pinches
it from above with the thumb and fore-finger of the left hand in a prone posi-
tion, brings the needle to the right or superior lip at a convenient distance
from the fissure, transpierces the fold, withdraws the thread, the extremity
of which is held by the assistant, or which he stays with a knot, brings back
tlie needle obliquely across the wound to the same side of the skin, three, four,
or five lines from the first puncture, and continues in this way until the last
stitch passes a little beyond the other extremity of the fold, so that the entire
suture shall present a certain number of spiral turns. If it does not appear to
be sufficiently closed, the two ends are drawn before being fiistened ; in the
contrary case, the lips of the wound are somewhat separated. If it is well
done, the lips of the wound, without being tiglit, should touch along their
whole extent, and the fold should be wholly eftaced. The suture is then
definitively finished, by passing each of the extremities of the ligature, like a
slip-knot, around the adjacent spiral. Wiien you wish to remove it, each
oblique loop is to be cut with the scissors, and then withdrawn singly ; or
you may merely unfasten the upper end, and then disengage successively the
different spiral turns, and draw it out entire by its lower extremity.
When both lips of the opening cannot be included in the same stroke of the
needle, each turn of the seamed suture is practised exactly as in the case of
suture with separate stitches, from which, in fact, as we have seen, it very
slightly differs.
§ 4. Zig-zag Suture.
This suture, the idea of which is attributed to Bertrand, is made with a
continued thread, the same as the one just described, and is begun and finished
in the same way ; but instead of crossing spirally in front of the wound, the
thread passes through the fold alternately from right to left and from left to
right, forming a complete zig-zag, which leaves the anterior aspect of the
bleeding surface entirely free and uncovered. In performing this suture the
needle traverses the tissue, beginning with the right border; being drawn out
by the left border, it again passes through, but in an opposite direction, a little
above, coming out by the right border; it is then returned on this side
some lines higher, and being again drawn out on the other, it is carried, as in
the first case, somewhat further, so that it proceeds in a serpentine, and not
in a spiral course, as in the case of the furrier's suture. Some surgeons
22 NEW ELEMENTS OF
ascribe to it the advantage of not tearing, or cutting the tissue so easily, in
consequence of the lateral loops which it forms between every two punctures,
and that it does not strangulate the parts like the other, by passing over them.
Admitting this to be the case, it must be allowed on the other hand that it
has the fault of drawing unequally the two halves of the wound, and of giving
no support to the anterior surface. Although slightly improved by Beclardy
the zig-zag suture is scarcely ever used, and can always, in fact, without
danger or inconvenience, give place to the interrupted, or to the seamed
suture.
§ 5. The Twisted Suture.
One of the sutures most in vogue, is that which is practised by means of
threads passed in different ways around metallic pins, which are allowed to
remain in the thickness of the flesh. Needles of iron, steel, gold, silver, lead,
copper, brass, &c., straight, curved, thick, thin, long, short, round, and flat,
have been employed in this operation; but at last this great variety has given
wav to the almost universal employment of ordinary pins, which are every
where at hand, and which are found in actual practice to answer every
purpose as well as needles of the most precious metals and most ingeniously
contrived. They are prepared by sliarpening and flattening the point upon a
stone, and covering them with cerate. If the wound is seated in a movable
part, such as the lips, or the eye-lids, the pin nearest to the free border of the
organ is the first applied, the others are afterwards successively inserted.
As this species of suture is to be minutely described in treating of hare-lip^
it would occasion useless repetition to detail here the particulars of the
operation. When the two extremities of the woUnd are closed, or it is
required to connect cutaneous flaps, the placing of the needles is not subject
to the same rules. The operator then commences at the centre, the
extremities, the point, the sides, or the base of the parts which he wishes to
bring in apposition, according to the difliculties which he thinks he has to
surmount. In this respect he must rely upon his own particular intelligence.
The right lip of the wound being seized with the fingers of the left hand, as
in the case of the interrupted suture, or with the forceps, the hook, or any
other operative means, according to the case, he plunges tlie prepared pin
from without inwards, and causes it to appear in the interior of the wound,
continuinjj to push against the other lip, which he seizes in turn and pierces
from withm outwards, so that the needle will come out at the same distance
up)n the skin. He embraces the needle immediately with a turn of thread
which he passes under the head and point, at the same time that it crosses the
front of the wound, and tends to press the two sides against each other. An
assistant takes the ends of this looped thread and holds them a little extended,
while the surgeon proceeds to the application of the other pins.
As soon as they are all placed, the surgeon proceeds to secure them by
casting the thread around them. The middle of a long ligature put above
the last, is passed and crossed many times around its extremities in the form
of a figure 8, then conducted in the form of a X to the next needle, and turned
in the same manner around its head and point before it proceeds to the third,
from which it is returned to the second and the first by renewed crossings.
He then concludes by knotting or twisting the two ends together, and turning
them under the body of the needle. To prevent these needles from wounding
the integuments, a small strip of plaster or roll of charpie is placed under
each of their extremities. Notiiing further is required, than some suitable
covering if such a thing is deemed requisite.
OPERATIVE SURGERY. 23
These are to be removed at the same time as all other sutures. We com-
mence bj the needle which supports the parts the least, so as to leave the
removal of the others until the next day, if we do not find a reunion suffi-
ciently solid. If there be any fear on this head it is proper only to remove
the needles and leave the thread a day or two longer, which, being attached
to the parts, and having become more or less consolidated, perform the office
of adhesive strips. This fear further requires that the surgeon should care-
fully support the right lip of the wound with the fingers of the left hand, while
with the other he draws out the needle by the head in a straight line, or by
giving it small rotatory motions.
The punctures which the needles leave suppurate a day or two, and
cicatrize like all other wounds of the same class.
§ 6. Quilled Suture,
The practice of infibulation, which is still in use among some of the oriental
nations, but which has for many years ceased to be used in Europe, except
to prevent the approaches of the male of certain animals to the female at
improper times, is a sort of quilled suture ; but instead of the metallic rods
used in operating upon the mare, this suture is effected upon a human subject
with threads and two small rolls of something more solid. The quilled suture
is performed in the same manner as the interrupted suture, but with double
threads, preserving a loop at one extremity. When they are all placed, a slip
of wood, the barrel of a quill, a bougie of elastic gum, or even a rouleau of
waxed cloth, or a small metallic rod, in short, any cylindrical body of a con-
venient length and thickness, is slipped along parallel with the wound into each
of the loops. The other extremity is then also undoubled for the purpose of
receiving a similar slip of wood or other body, upon which the threads are
successively tied, having previously secured an accurate apposition of the
edges. Care must be taken not to exercise too forcible a constriction, nor
yet to allow any gaping of the sides of the wound.
Altliough rarely indispensable, the quilled suture has always the advantage
of exercising a pressure perfectly equable upon all the points which the thread
is intended to bring together, of being more firm than any of the others, of
being less apt to lacerate the parts, and of being particularly adapted to
straight, long, and deep wounds of the walls of the abdomen and of the limbs.
The only objection to this suture is, that it requires a little more time and
care than the continued suture.
In using any species of suture, we must avoid needlessly multiplying the
stitches or leaving them too far apart. The intervals must vary according as
the strain to be opposed is more or less considerable — the incision more or
less extended — the parietes to be repaired more or less flaccid — more or less
difficult to be kept in apposition. A stitch for every half inch is generally
sufficient; while there are cases which require one in every three lines, and
others in which the stitches may be an inch apart. What has been here said
however, cannot be fully understood without the aid of particular examples,
which would here be out of place.
d4 ^. NEW ELEMENTS OF
COMPLEX OPERATIONS.
OPERATIONS UPON THE BLOOD-VESSELS.
CHAPTER I.
OPERATION FOR ANEURISM.
The true aneurism or a dilatation of all the arterial coats (•* the circum-
scribed arteriectasis"), so lonff admitted as the most common, but the existence
of which has been contested by Scarpa and Delpech, although really very
rare, has yet been sometimes obseiTed. Hodgson cites several examples :
M. Floret declares that he has seen a number situated at intervals on the first
four intercostal arteries, and M. Berard, sen., has deposited in the museum
of the faculty a preparation, which leaves no doubt upon the subject. It
will be perceived in the preparation, that on its passage between the pillars
of the diaphragm the aorta presents a fusiform swelling as large as the fist, in
which three arterial coats are still distinguishable ; the root of the cceliac
trunk, which corresponds with the middle of the tumor, is itself much dilated
and spread out like a funnel, and the same appearance is presented by the
superior mesenteric.
Another species of true aneurism can now be established, which also some-
times claims the assistance of Operative Surgery. It is the diffused Arteri-
ectasis, which only affects the arteries of the fourth or fifth order, which are
then thickened, dilated, and contorted, as if aff'ected with hypertrophy, and
somewhat similar to varicose veins. It, however, occupied the femoral as
well as all the other arteries of the leg, in a case which was treated last year
by M. Dupuytren, at the Hotel Dieu. Park has seen the posterior tibial
artery in tnis state, and Pelletan the occipital, temporal, and frontal, in the
same subject. All the arteries of the hand and of the fore-arm are some-
times thus aflfected, as I once had an opportunity of observing at the lectures
of Beclard.
Perhaps it would be well to give the name of true aneurism of the capillary
system to those erectile tumors which have already received so many appella-
tions, and which appear to have been encountered even in the thickness of
the bones.
False Aneurism, which is characterized by a rupture of some of the coats,
or of the whole tliickness of the arteries, ought, in theory at least, to bear
another denomination, but practical utility rules, and this custom, though by
all acknowledged to be vicious, is yet by all observed.
OPERATIVE SURGERY. 25
Tlie primitive or diffused false Aneurism arises from the opening of an artery,
and consists of an effusion of blood, more or less considerable, in the
neighborhood of the lesion, and in that particular diflfers essentially from all
other kinds of aneurism.
In the circumscribed false Aneurism some foreign body has perforated the
artery, but the blood, escaping by degrees through this opening, forms for
itself a sac at the expense of the surrounding cellular substance, and of the
external coat of the wounded vessel.
If the blood pass directly from an artery into a vein, by an opening in the
adjacent coats of these two vessels, an aneurismal varix is the result.
If a sac is formed in which blood may accumulate between the opening in
the artery and that in the vein, there is a false circumscribed aneurism
complicated with an aneurismal varix^ or as some would style it a varicose
aneurism.
Mixed Aneurism, or that which is formed by the spontaneous solution of
the continuity of a part of the coats of an artery, and by the mechanical
dilatation of those which are sound, presents itself, according to authors,
under two forms. Sometimes the internal coat distends itself and bulges out
so as to form a cyst through an opening in the other two, and which constitutes
internal mixed aneurism, or aneurismal hernia; at other times, on the contrary,
it is the external or cellular coat alone which dilates and receives the blood
through a perforation of the internal and middle coats : this is an external
mixed aneurism, or mixed aneurism, properly so called.
But there is no proof that the first of these two varieties is really possible,
or that it has ever been positively observed : tlie fact which is attributed in all
the books to Messrs. Dubois and Dupuytren, and which is brought fonvard
in demonstration of its existence, is not conclusive. The experiments of
M. Casamayor on dogs, and the new observation which M. Dupuytren has
just communicated, do not appear to be mu«h more so. Those of Haller,
who has seen, in operating upon frogs, the internal coat of the mesenteric
artery form a hernia through the lesser and external coats, can have no
weight here, as it will be more easy to explain, together with all that relates
to aneurism, after having briefly sketched the surgical anatomy of the arterial
system.
SECTION I.
Anatomical Remarks,
Every artery of any considerable size is composed of three coats, three
concentric cylinders, very distinct in the great trunks, but which mix insen-
sibly with each other as the vessel diminishes and can no longer be separated
when it approaches its capillary extremity.
1st. The Middle Coat, also designated as the muscular coat, the yellow
coat, the tunica albuginea,is composed of incomplete fibrous circles, and not
of longitudinal fibres, united to one another by lamellas and filaments of the
same nature ; no vessels, either lymphatic or carrying red blood, are to be
traced in it, although certain observers have pretended the contrary ; it is
almost inert, and breaks like glass ; if it is tightly encircled with a thread it
tears, instead of being distended when it is subjected to a pressure superior
to its natural power of resistance. Although it is elastic like the yellow
tissue of tlie trachea and the ligaments of the vertebrae, which it to a certain
4
Xb NEW ELEMENTS OF
point resembles, it is almost impossible to draw this coat in a direction
•parallel to its axis without breaking it. By its outer surface it is united to
the external coat, through the intervention of an irregular layer of laminar
tissue, imperfectly organized ; on the inside, the internal membrane is connected
-with it by a simdar medium. As this tunic is devoid of sensibility, and of
almost all the properties of animated matter, it is not astonishing that the
diseases of which it is the subject should be in great measure independent
of the vital phenomena, and should seem to develop themselves under the
influence of the laws which govern inanimate matter. It is this coat which
distinguishes the arteries from the veins, keeps them patulous after they have
been cut across, determines their form and color, renders inflammation of these
vessels so difficult and rare, prevents wounds or incomplete divisions of them
from cicatrizing by aggktination, and enables them better to resist the lateral
pressure of the blood. As the arterial trunk approaches the heart and is
enlarged, or when it is destined to sustain a greater pressure, the middle coat
is increased in thickness, and that rather more on the convex side of the curve
than on the other. When it has reached the branches of the fourth or fifth
order, and is approaching the final ramifications of the arterial system, it is
observed gradually to become thinner and less distinct, until, at last, it is
confounded in a common tissue with the other coats of the vessel. From
this it follows that, all other things equal, the arteries are more flexible, more
extensible, and less easy to rupture, in proportion as they are smaller and
farther removed from the centre of the vascular system.
2d. The Internal Tunic, which has been compared by some to a mucous,
and by others to a serous membrane, is smooth and generally unctuous on its
free surface : on the other it adheres to the preceding coat only by a thin layer
of laminar tissue, in which there exist no vessels, nor indeed any other
eleuientary organ. This coat contains no fibres or vascular canals of any
description, and is in fact nothing more than a lamella of a homogenous sub-
stance something like the cornea, the substance of the nails and tlie corneous
tissue in general, facilitating the passage of the blood through all the ramifi-
cations of the arterial tree. In the small and capillary branches, this layer
is no longer separated from the cellular tunic by the middle membrane, but
approaches more nearly the character of a really organized substance,
admitting the fluids on its external surface by direct circulation ; besides, it
is thicker and more distinct, but extremely fragile. It is separated from all the
rest of the vascular system by the yellow tunic, and is an almost inorganic
layer like the cartilages, endued with very little elasticity, and very easily
destroyed. From these characters, it results that the inner membrane of
the arteries cannot be primarily inflamed ; that it can only become the seat of
this pathological phenomenon by transmission from the surrounding tissues;
in short, that it is subject only to mechanical derangements, unless it receive,
by contact from the other tunics, the diseases with which they may be affected.
Sd. IJie External or Cellular Tunic is the only one which presents all the
elements of an actual tissue ; it is formed of small fibres and lamellae variously
interlaced, like all the other cellular sheaths ; fine arterial and venous
branches, run through it in every direction. These vessels, known by the
appellation of «* vasa vasorum,^^ supply the entire thickness of the artery,
yet do not penetrate into the middle tunic, nor, of course, into the internal;
80 that the cellular membrane is the only one in which there is a real circu-
lation, and the others, either are not nourished at all, or only keep themselves
in their natural state by imbibition, or by simple deposit of molecules. Thi«
OPERATIVE SURGERY. SUt
texture of the external tunic of the arteries allows it great extensibility,
permits it to yield without rupture to all impressions made upon it, to inflame,
to cicatrize, to contract adhesions with the tissues about, and to transmit to
the other coats its peculiar diseases ; whence it follows, that in the capillary
system, where it forms nearly all the thickness of the vascular walls, life is
more active, and diseases infinitely more frequent.
4. Besides the cellular coat, the arteries are again covered throughout by a
sheath of similar structure, but much less firm; this sheath, which, is
denominated the " common skeathP analogous to that which envelopes all the
cords, and all the fascicles or assemblages of fibres in the system, increases
and preserves the inflexibility of the former, connects it to the neighboring
tissues, and principally to the collateral veins.
5. Further, the arteries are every where connected with parts more or less
solid and fixed. In the breast and the abdomen the aorta receives no solid
support, except from the vertebral column against which it is applied, so that
the aneurisms which occur in it, even if they originate on its posterior side,
generally project in a lateral direction, or even in front. The branches which
it gives m the visceral cavities resting upon no solid bed, would seem from
this circumstance more subject than any others to dilatation or to rupture.
But the support which they receive from the pressure of the viscera, the great
freedom of motion which they enjoy, and the slightness of the impulse made
upon them by external agents, explain their great exemption from these
affections. In the limbs, where they are surrounded by muscles, and sup-
ported and protected by bones, the arteries appear at the first view to have
less to fear from the causes of aneurism ; but since they are there obliged to
follow all the great movements of the frame without possessing the same
freedom of motion, as in the abdomen for example, and since the elongations
and stretchings of every kind to which they are there subjected expose them
to frequent rupture, we have no difliculty in conceiving how they should
become on the contrary so frequently diseased — how the ham, the groin, the
bend of the elbow, and the armpit, should present so many instances of spon-
taneous aneurism, while they so rarely occur in the leg, the thigh, the arm or
the fore-arm.
6. The arteries receive their nerves only from the plexus of the great
sympathetic, and these, like the vessels, are never traced except in the cellular
tunic. On the outside however, they are generally accompanied by nerves
of the cerebro-spinal system. While we are on this subject, it may be well
to mention the law imagined by M. Foulhoux : that with arteries of any
considerable size in the superior division of the body, the collateral nerve
is always placed on the outside, that is, on the side most remote from the axis
of the part, while on the inferior limbs the reverse generally obtains.
SECTION II.
Spent aneotis Cure,
Aneurism is always a dangerous disease. Left to itself, it seldom stops
short of the destruction of its subject. The parieties of the cyst become
more thin as it expands, or gangrene by degrees; the blood and clots
contained in the tumor escape, and a profuse hemorrhage ensues, which ceases
only with life. It is yet true, that with some persons such a termination
may be a long time deferred ; that patients have carried for many years, even
S8 KEW ELEMENTS OF
for twenty years, as in one case reported by Saviard, one, or even several
aneurisms, without beinc seriously incommoded.
But it must not be understood that nature never succeeds in overcoming
aneurism ; on the contrary, authors relate a considerable number of spon-
taneous cures of this disease.
M. A. Scverin has seen gangrene attack the whole of an inguinal aneu-
rism, and the patient recover. Lancissi cites an observation of an
aneurism of the thigh, which, after having acquired a considerable volume,
gradually diminished, and at last entirely disappeared. Reinig published,
in 1741, an observation of a traumatic aneurism of the femoral, which healed
without operation or gangrene. Guattani, Paoli, Moinichen, Clarck, and
Albert, each report an example of aaemism terminating in gangrene, and
spontaneously cured. In the dead body of a young woman, Mr. Freer, of
Birmingham, discovered a tumor about the size of a small apple, entirely
filled with solid layers, and which had formerly communicated with the
interior of the aorta. Mr. Marjolin speaks of an aneurism of the femoral
artery, which resulted in a large abscess, and afterwards healed. But
observations of this kind are so familiar at the present day, that it will suffice
to refer to them when treating upon each particular artery.
In order to attain this happy result, nature employs different processes. 1st.
The entire aneurismal bag may be attacked with gangrene ; the fluid which it
contains is decomposed, the blood coagulates above and below the perforation
in the artery, and sometimes becomes solid enough to completely interrupt
the circulation in this point, and to permit the tumor to open and empty itself
without danger. The wound whick results is cleansed, suppuration is
established, and a cicatrix is formed without the occurrence of the slightest
hemorrhage.
2. Chronic inflammation may affect the partitions of the cyst, and the
surrounding laminae may extend itself to the arterial trunk, form an actual
abscess, occasion an effusion of coagulable lymph above and below the point
of the artery which communicates with the aneurism, and produce there
adhesions sufficiently firm to resist the impulse of the blood, so that the
purulent collection will be enabled to open and to discharge itself without
involving greater danger than any other abscess.
3. The tumor, when it is supported by muscles, by aponeurotic expansions,
or by dense laminae of cellular tissue, is sometimes filled up with successive
and concentric layers of fibrin, and acquires sufficient size ana firmness to react
by its superior part against the arterial trunk from which it arose, so as to
obliterate it, if it bears it against any solid point, and thus to suspend the
circulation through this part of the artery. Then all the blood contained in
theaneurismal cyst, coagulates ; its more fluid part is absorbed ; the molecular
action diminishes by degrees the mass of the more solid elements, and the cure
of the aneurism is eff'ected.
4th. In other cases of much less frequent occurrence, the different concrete
layers which successively line the interior of the cyst at last entirely fill it
up, and even form in the opening in the side of the artery, and acquire such
a consistence that the blood cannot displace them. They then increase in
thickness, approachingby degrees the axis of the vessel, until at last they close it
entirely, and thus put an end to the circulation through that part.
5th. Finally, in the other cases still more rare, these concretions, after
having completely filled the sac, dispose themselves in such a manner as to
close exactly the lateral opening of the artery, which preserves its calibre
without preventing the resolution of the aneurism. It was so in the case
OPERATIVE SURGERY. 29
spoken of by Mr. Freer. Sir A. Cooper has met with a disposition still more
remarkable. The femoral artery, says he, had been the seat of a true aneurism,
the interior of which, lined with very firm fibrinous layers, preserved in its
centre a cylindrical canal having the same dimensions as the remainder of
the artery. This is however, a disposition which appears to have been observed
by Guattani, and of which Roe, surgeon in the navy, also thinks he had seen
an instance on the iliac artery ; but is it certain that a true aneurism existed
there ?
While aneurism was thought to be most commonly formed by the simulta-
neous dilatation of all the tunics of the artery, a hope had been indulged of
curing it by maintaining the calibre of the vessel in its natural state. It was
thought that by skillful management the aneurismal sac might be forced to con-
tract upon itself to resume by degrees the place which it had occupied before, and
to restore to the artery its primitive calibre, and all the attributes of the normal
state. Scarpa has endeavored, on the contrary, to establish it as an axiom, that
the radical cure of aneurism cannot take place, whatever may be its situation,
unless the corroded, lacerated, or wounded artery, be to a certain extent above
and below the place of its morbid change converted into a solid and ligament-
ous substance, whether this process be effected by nature or by art. Although
such a proposition may be generally true, it is yet liable to some exceptions,
even if there were only the observations of Messrs. Cooper and Freer, which have
just been quoted, and some others which may be found in the works of M. Hodg-
son, to oppose its universal acceptation. Scarpa himself relates a fact which
contradicts his own assertion. A patient attended by Monteggia, died twenty
months after having had the humeral artery pierced by the point of a lancet.
The aneurism had been for a long time healed ; the artery had preserved its
calibre,whileinthe interior of this vessel a cicatrix was discovered, supported
on the outside by a small clot, blackish and very hard, corresponding to the
original wound. Observations more or less analogous have been recorded by
Saviard, Petit, Foubert, and others. Yet it would be very wrong to count
upon a termination like this ; it is too rare to permit us to endeavor of choice
to obtain it. It is but an exception which does not impair the correctness of
tlie principle of Scarpa.
SECTION ni.
Curative Methods.
The aim of surgery, in the treatment of aneurism, should be to effect the
most surely, the most promptly, and with the least pain possible, tlie obliteration
of the affected artery.
In order to attain this end, different methods have been tried.
1st. Internal means, and regimen.
2d. Topical applications.
Sd. Mediate compression.
4th. Cautery ; absorbents and immediate compression.
5th. The ligature, suture, fraying, acupuncture, and torsion.
Art, 1. — Method of Valsalva,
Valsalva and Albertini, while yet students of medicine, resolved to treat tht
first subject that they might encounter afiiicted with aneurism, by biteding
so NEW ELEMENTS OF
and a weakening regimen. This is their manner of proceeding. The patient,
after being bled once or twice, is confined to his bed for forty days, and allowed
during that time barely sufficient aliment for the support of life. His allow-
ance of nourishment is to be gradually increased, after the weakness induced
hj this treatment has almost disabled him from raising his arms or turning
himself in bed, Hippocrates had before said, that in case of hemorrhage of the
lungs the best method of treatment is to bleed the patient freely and frequently,
until he is almost drained of blood, and to reduce him by diet to a state of ex-
treme leanness. Lancisi, Guattani, Corvisart, Pelletan, Hodgson, Sabatier,
Boyer, Yatmann and others, have obtained from this treatment, some advan-
tageous results, and have even effected cures, if the annals of Hecker, for 1828,
are to be believed. Yet it must be confessed that there is a difficulty in believing
in its efficacy. There is no doubt that, by repealed and frequent bleedings and
a low diet, the impulsive force of the heart and the throbbings of the aneurismal
tumor may be reduced, and the volume of this tumor may be, in the greater
number ot cases, diminished ; but is it not to be feared, that in weakening the
patient, we majr increase the fluidity of the blood, and that, so far from favor-
ing the concretion and solidification of the aneurism, and the obliteration of
the artery, we may render these results more difficult to obtain. When it is
recollected with what facility the least emotion, the slightest movement produces
tumultuous palpitations of the heart, and that, by thus reducing the patient to
anemia we render him incapable of supporting the most trifling operation,
and that the slightest indispositon may then be fatal; when it is further
remarked, that up to the present time the cures obtained through the method
of Valsalva are but very limited in number, if those alone are counted which
belong to it exclusively, may we not be permitted to contest its importance ?
The opinion which I have here advanced, is also very much in accordance
with that of M. Dupuytren, and may be found in several theses defended
before the faculty of Paris within a few years past.
Nevertheless, blood-letting and an enfeebling regimen should not be
rejected in the cure of aneurism. When the disease is seated in the aorta
beyond the reach of operation, it is then prudent to have recourse to them,
and to join with them the preparations of digitalis, so much extolled by
Yatmann, Brooke, and other English surgeons. Some facts reported by
Pelletan, Sabatier, Roux, and others, induce us to believe that this compound
treatment is not entirely without efficacy, and should not be rejected when
nothing better can be attempted. The reduction of the force and frequency
of the circulation, which is usually effected by the preparations of digitalis,
together with a sensible but moderate diminution of the volume of the blood,
"Will, it is to be hoped, permit the fluid contents of the aneurism to coagulate
and the whole tumor to become hard, particularly if the orifice by which it
communicates with the artery be irregular and small. We may conceive
also how such a tumor, resting upon an artery, might cause its obliteration;
because the pressure which it exerts, although insufficient in the natural state,
had then become strong enough to resist the diminished impulse of the heart.
Art. 2. — Refrigerants and Styptics*
Almost all the older authors profess to have cured aneurisms by the use
of compresses steeped in astringent liquids, or formed of astringent substances,
of various plasters, of little bags filled with tan, of decoctions of bistort, oak,
and willow bark, walnut leaves, of camphorated spirits, vinegar, or hot wine.
They thought in operating in this manner to force the artery to contract upon
OPEKATIVE SURGERY. 3f
itself. Others employed cold applications. T. Bartholin, for example, is said
to have cured an aneurism of the arm by the lepeated application of snow.
But we are indebted to Mr. Guerin of Bordeaux, for the knowledge of the
importance of topical refrigerants in such cases. In 1790, a carman was
admitted into the hospital of St. Andre, afflicted with an aneurismal tumor,
which finally occupied all the supra-clavicular region, and a part of the neck.
Several blood-lettings, a ptisan with the eoAi de Rabel, and the use of com-
presses steeped in oxycrate, placed over the tumor, succeeded in the space of
a few months in effecting a cure. In 1795, M. Treyran treated an enormous
aneurism of the femoral artery by the same means and with the same success.
M. Guerin, jun.has since reported several similar examples. In 1799, Sabatier
put an invalid, affected with aneurism of the ham, upon soup and boillou for
his whole nourishment, prescribed an acidulated ptisan, applied ice to the
tumor, and cured his patient in the space of four months. Pelletan also had
recourse to cold applications, at the same time that he was trying the method
of Valsalva. Since then Mr. Hodgson, M. Larry, and others, have reported
fiicts, which tell in favor of the method of Guerin. It is then a means to
which we may resort, when the more certain methods we possess are not
applicable, or when the patients are not willing to submit to them. It may
be employed singly, or combined with that ol Valsalva, with the mediate
compression, or with the due application of a certain number of moxas, as it
appears to have been practised many times by M. Larry with advantage.
There is nothing about the action of this remedy but what it is very easy to
comprehend. Under the influence of such topical applications, the heat of
the part is very much diminished ; the circulation there becomes less active,
the blood which has been effused loses its fluidity, and has a strong tendency
to coagulate ; and if the disposition of the parts and the state of the system
are favorable to such a termination, the artery is closed and obliterated, and
the cure is complete.
ARTICLE KI,
Compression.
§ 1. Mediate Compression,
Aneurism of the carotid, and of the subclavian, have been cured by Acrel,
by means of a gradual compression exerted upon the tumor. Those of the
ham, the^ thigh, the groin, the hand, and the elbow, have been treated with
success in the same manner, by F. de Hilden, Saviard, Tnlpin, Weltin,
Dehaen, Leber, Plenk, Petit, Theden, Guattint, and many others, so that it
is not possible to doubt the efficacy of this method. But it has been used in
a great variety of ways: sometimes the compression is only applied upon the
aneurism, at other times upon the aneurism and the other parts of the member
at the same time, and again it is applied either above or below the tumor.
1. On the Tumor, or the affected point. — Galen is one of the first who made
use of compression in the treatment of aneurisms ; by means of plasters and
pieces of sponge, confined by bandages, he perfectly succeeded in a case where
the artery had been opened in the act of blood-letting. From the days of
Dionis, it has been a common practice to apply pledgets of chewed paper, of
agaric, or of tinder, confined by a piece of money, and over these, other masses
of the softer material still larger, so as to form a pyramid, of which the point
should correspond to the opening of the artery, and to confine the whole by
92 NEW ELEMENTS OP
means of appropriate bandages. The Abbe Boudelot records, that he was
himself cured of a false consecutive aneurism, bj carrying for the space of
one year a little cushion firmly pressed upon the tumor.
Since that period, and especially in the first half of the last century, the
improvement of this species of compression has been an object of much
attention. Arnaud, Heister, Ravaton, Leber, and others, have proposed
different bandages, with the intention of rendering it more easy and more
secure. Each endeavored to modify the compressor of Scultet, or the tourni-
quet of J. L. Petit, and each imagined that he had found the means of curing
aneurisms without an operation. Foubert constructed a steel ring of an oval
form, having on one of its longer curves a metallic plate furnished with a
cushion, and pierced on the opposite side by a screw bearing upon its extre-
mity a second cushion like the first. This ring, when applied, was intended
to press only upon the diseased point and the part of the limb diametrically
opposite. This machine, although more ingenious than many others, and far
superior to those plates of lead, of silver, or of iron, with or without cushions,
or sponges, to be confined upon the aneurisms by the aid of ribbons, straps,
or bandages, has yet the serious inconvenience of being easily deranged, of
not establishing the compression except upon a diseased part of the artery and
that of slight extent, of producing engorgement in the parts below, and of
being insupportable except by a small proportion of subjects.
2d. Compression on the whole extent of the limb. — The compression of the
whole length of the aftected part should then be deemed preferable to local
compression. Gengha practised it in the following manner: — I apply, says
he, to each finger a little strip in the form of an expulsive bandage, then I
envelope in the same way the hand and the forearm almost to the wound ; I
then place on this latter a large compress of fine linen soaked in a mixture of
terra sigillata, bol ammoniac, dragons' blood, hematite, white of egg, and
plantain ; I apply over this a thick plate of lead, some compresses, and three
or four turns with a bandage passing above the elbow ; then I fix with the
same bandage over the passage of the artery, on the internal face of the arm,
a wooden cylinder enveloped in linen, after the manner of a splint ; I then
return my bandage over the wound so as to confine it by several turns, after
which I moisten the bandage with some astringent liquid, and put my patient
on a very spare and cooling regimen.
This is what is generally called the bandage of Theden, who previously
applied to the tumor compresses steeped in eau vulneraire. In using this
method the infiltration of the part is not so much to be apprehended ; the
pain is less lively, and the compression is more easily to be supported ; but,
on the other hand, the circulation by the collateral or supplementary arteries
is by the same means rendered much more difficult than by the other method ;
the more so in proportion as it is necessary to compress with greater force.
3d. Compression below the Tumor. — According to M. Caillot, who said that
be received it from M.Boyer, a military surgeon, M. Vernet, conceived the
idea of curing aneurism upon the limbs by a compression applied upon the
course of the artery at a point situated below the tumor. He tried this
method on a patient affected with inguinal aneurism, but the pulsation increased
with such force in the cyst, that he was soon forced to relinquish his design.
This method has been generally blamed, even by those who have adopted the
idea of Brasdor on the subject of ligature ; but yet it does not seem worthy
of entire rejection. If, for example, it were necessary to treat an aneurism,
above which it would be impossible, or at least, highly dangerous to apply
compression or ligature ; if on the other hand, no important branch were
OPERATIVE SURGERY. 33
furnished between the cardiac extremity and the free part of the tumor, it is
by no means certain that, by compressing the artery on tins latter point, you
will not succeed in suspending the circulation in the aneurism, in occasioning
the formation of a solid coagulura in its cavity, and, in short, of producing the
obliteration of the arterial canal, and a perfect cure of the disease.
Compression above the Tumor. — Finding that the bandage of Theden and
that ol Guattani, and all other instruments for effecting partial compression
tend to impede the circulation in the limb, or else to cause the rupture of the
aneurism if it do not yield to their application, surgeons have happily
thought to compress the diseased artery at the point where it is most super-
ficially situated, between the tumor and the heart. Mr. Freer has strongly
recommended for this purpose the bandage of Sennefio. That practitioner
first encompassed the whole extent of the limb with a rolled bandage,
moderately tight, and placed a pad some inches above the tumor. A plate
was then applied to the opposite surface of the part, which he encircled with
the tourniquet so as to compress the artery upon a single point with a few
turns of the screw^ After some hours, says Mr. Freer, the limb becomes
oedematous and swells : at that time the tourniquet may be removed, and a
pad with a bandage tolerably tight is all that is further necessary. This
bandage, which is a combination of those of Theden and of Foubert, appears
to me to afford some probability of success. M. Dubois effected the cure of
an aneurism of the thigh, by making use of it as a species of spring, con-
structed on the principles of the tourniquet of Petit, and acting only on two
very circumscribed points of the limb. M. Albert, of Bremen, has derived
the same advantage from a bandage, which he denominates the '' inguinal
compressors'^ which is composed of a little cushion designed to be applied
against the pubis, over the passage of the femoral artery, and of two straps
which embrace the whole circumference of the pelvis and the root of one of
the thighs. M. Verdier has arrived at the same result, by means of a
bandage which has some analogy to the herniary bandage of Camper. M.
Dupuytren has constructed another, composed of a semicircle of solid steel,
which is surmounted at one end by a large, thick, and concave cushion, to be
applied to the surface of the limb opposite the artery ; on the other extremity
is a plate of iron which supports, with the aid of two stanchions and a screw,
a rounded pad, which may be brought nearer to the first cushion, or removed
farther from it, and which is to be applied over the artery. It appears that
with a species of dog-collar, M.Viricel, in the hospitals at Lyons, met with
the most decided success by compressing the artery above the tumor. M.
Morel, who relates these cases in his thesis, advances the idea that success
would be rendered more certain if the compression were exerted at the same
time on several points of the limb. Lastly, Mr. Blizard and Sir A. Cooper
have described another instrument, not less ingenious than those which have
been mentioned. A long piece of steel is first fixed upon the outer face of
the knee, and of the great trochanter ; from the centre of this piece, another
piece advance's in a semicircle towards the femoral artery, and carries on its
extremity a plate provided with a cushion capable of being moved by a screw,
and of compressing the artery to the interruption of the throbbings of the
aneurism, without impeding the circulation in the smaller vessels. Com-
pression employed in this manner, may, no doubt, succeed, and ought even
to be practised in some cases ; such as aneurisms in the neck of the subcla-
vian artery, or of the superior part of the femoral, if any circumstance should
occur to prevent the use of the ligature ; in other cases it would rarely be
found beneficial. The patient spoken of by Sir A. Cooper, was only able to
5
S4 NEW ELEMENTS OF
bear it for a few hours. With one of those under the care of M. Dupuytren
it was necessary to apply the bandage successively upon several dift'erent
parts of the artery, ana very shortly to relinquish entirely the employment of
this mode of compression. M. Roux relates a similar case ; and it required
all the fortitude and resignation of the patient mentioned by M. Verdier to
prevent him from throwing off the apparatus several days after the experi-
ment had been begun. It may, however, without hesitation be affirmed, that
compression will cure a certain number of aneurisms in whatever way it may
be applied, although the method of Guattani, or that of Theden, appears
preferable to all the others.
To draw from compression all the advantage possible, it is necessary to
associate with it a regimen somewhat severe, uninterrupted repose, and the
employment of refrigerants or astringents ; not forgetting, however, that it
has succeeded without these adjuncts, even with patients who have not
refrained from the most fatiguing exertions, as we see in the man whose case
is recorded by Lassus, who after having applied a bag filled with cinders,
and fixed by tour long linen bandages upon an aneurism of the thigh, thought
that he should facilitate his cure by taking every day a hard walk, and using
other active exercise to which he had been unaccustomed, and who yet suc-
ceeded, at the end of eight months, in getting rid of his disease. If compression
had not been superseded of late years by the ligature ; if it did not act at
tlie same time upon the veins, and sometimes also upon the nerves ; if it
were true that it had at least the effect of preparing the way for the successful
use of the ligature, by forcing the collateral arteries to dilate, and that it was
never dangerous ; it certainly would be wrong to neglect it, or not to have
recourse to it in particular cases. But the use of the ligature has now become
so easy and simple, that it is really almost impossible to accord to other
methods any considerable degree of estimation.
Down to the time of Scarpa compression was recommended with ardor,
because it seemed capable of causing the disappearance of the aneurism
without obliterating the artery. J. L. Petit ventured to set himself up in the
academy of sciences the champion of this hypothesis. According to him,
when an artery is laterally opened, if it is compressed the blood diffused
among the surrounding tissues coagulates and hardens ; a portion of the clot
stops in the wound of the artery, and there contracts such adhesions that it is
impossible afterwards to dislodge it, although the artery itself preserve its
calibre and the other characteristics of its natural state. '* When the blood
is stopped," says Foubert, " the wound upon which a sufficient compression
has been made, closes; the skin, the fat, and the aponeurosis, cicatrize;
while the incision of the artery does not reunite immediately, but leaves a round
opening in which rests a small clot of blood. The compression, continued
long enough to secure the induration of the clot, radically cures the disease ;
but if the arm is permitted to be moved before the clot has acquired a proper
degree of solidity to cement the adhesion of the tissues, it escapes from the open-
ing, the blood insinuates itself around it, and removes it from the place which it
has occupied." Examples have been given in support of this theory by Petit,
Morand, Foubert, and some others. It has since, however, been established
as a general truth, that the cures thus obtained were not radical ; that the
clot of blood, the cork or nail, as it was called by Petit, which fills up the
opening in the arterj, never identifies itself with the tissue of the vessel, but
that sooner or later it is expelled, and a new aneurism makes its appearance.
So in the experience of Saviard, a patient who had apparently been cured of
an aneurism in the arm, saw the tumor reappear after a lapse of fifteen years,
OPERATIVE SURGERY.
in consequence of an effort: it is useless, then, to attempt the cure of
aneurism by compression, otherwise than by the obliteration of the artery.
This point established, it only remains to determine which among the
methods that have been invented is the most likely to produce the desired
effect. Scarpa thinks it absolutely necessary that the two opposite sides of
the canal should be placed and maintained in contact for a certain time, and
that compression upon the tumor produces this effect with difficulty ; conse-
quently, he recommends that the artery should be acted upon above the
tumor, excepting however recent traumatic aneurisms. Experience is not
in accordance with the opinion of Scarpa. Guattani cured four aneurisms
out of fifteen, which he treated by applying the bandage upon the tumor
itself. Flajani obtained the same proportion of success under the same
circumstances, and every day announces similar cures.
The aneurismal varix, first observed by Sennert, and afterwards so well
described by Guattani and W. Hunter, is better suited than any other
species of aneurism to the compressive bandage, and frequently yields to its
application. The two Brambilla, Guattani, and Monteggia, relate each an
instance. It is a palliative at least, even if it do not produce a radical cure.
An elastic sleeve, even a simple laced stocking, will arrest the progress of the
disease, and enable the limb to perform its usual functions without causing
the sliglitest danger to the patient. A lady who had been thus treated by
Scarpa, wrote to him at the expiration of fourteen years that she did not
experience the least inconvenience in the affected arm, except a slight occa-
sional numbness.
If Cleghorn, instead of directing his patient to change his profession of
shoemaker for that of hair dresser, in order that he might hold his arms in
elevated position, had employed compression, he most assuredly would have
derived results equally advantageous. For the rest, since after the expiration
of thirty -five years the patient spoken of by Hunter had not become worse,
since in three different cases Pott did not feel obliged to operate, and
B. Bell, as well as Bertrandi and many others have made a similar observ-
ation, prudence and humanity require, where there is no special counter
indication, that before resorting to the ligature we should make trial of simple
compression in cases of aneurismal varix.
If it is intended only to confine the parts within their natural limits, the laced
stocking, or the simple rolled bandage of Theden will be found sufficient;
but if a radical cure is to be attempted, this treatment demands additional
precautions, the same in fact as for the other sorts of aneurism, that is to
say, that besides the rolled bandage, exactly applied from the free extremity
to the root of the member, where it is finisned with one or two turns spica-
wise round the trunk, it is necessary previously to place upon the tumor, if
there be one, pieces of lint, sponge, or graduated compresses, steeped in cold
and discutient liquids; to fix a pad upon the passage of the artery between
the wound and the heart, and to add above, like Sennefio, a compressor like
that of Foubert, or of M. Dupujtren.
Whenever the affected arteries rest upon bones, or other solid parts capable
of affording a sufficient counter-resistance, and where they are only removed
from the surface of the body by the common integuments, the aponeurosis, or
<:ellular tissue, compression offers every possible advantage, and ought to be
frequently employed.
S6 NEW ELEMENTS OF
§ 2. Immediate Compression,
Surgeons have frequently found themselves unable to tie an artery which
they have opened either by accident or design ; they have then been obliged,
in order to preserve the life of the patient, to fill up the wound and compress
the vessel, applying directly to it the substances so much extolled by Trew,
Teichmeyer, &c. This sort of compression, which is much less frequently
used than mediate compression, is also in lact much less advantageous, and
ought to be completely excluded from the practice of the present day. Guat-
tani having occasion to treat a very voluminous aneurism of the groin, caused
it to be opened by Maximini, with the intention of applying im?,.odiately upon
the artery, at the bottom of the sac, and against the pubis, graduated
compresses firmly confined by a bandage. Every thing succeeded according
to the wish of the surgeon ; the dressings were removed at the expiration of
thirteen days, and the health of the patient was perfectly re-established.
A patient under the care of Mayer was afflicted with an aneurismal tumor
in the groin, as large as the head of an infant. That surgeon, at first believing
it to be a hernia, resolved upon exposing it for the purpose of effecting its
reduction, and did not discover his error until after he had divided the
common integuments and the aponeurosis. A great quantity of bloody matter
which had accumulated between the cyst and the adjacent parts was removed.
Instead of opening the tumor, the pulsations of which sufliciently indicated its
nature, Mayer contented himself with establishing upon it an exact pressure
which he afterward renewed with the greatest possible care. The patient
recovered.
Desault, in a case nearly similar, embraced the upper portion of the artery
with two flat pieces of wood, connected by a piece of thread, in the form of
pincers, and was thus enabled to pass the ligature; but this conduct, although
pardonable at that time, would be justly censured at the present day. If the
aneurism is so much elevated as not to permit the exposure or compression of
the femoral artery between the tumor and Poupart's ligament, a ligature is
applied to the iliac artery, without exposure to those dangerous consequences
which Guattani and Desault escaped only by a sort of miracle. Sabatier him-
self thought it necessary to use immediate compression for an aneurism in the
superior third of the thigh. The patient was a young man of twenty-five.
Two tourniquets were applied, the one upon the hollow of the groin, and the
other a little below. When the tumor was opened and cleared of the clots of
blood, the opening in the artery was seen perfectly round. Sabatier passed
under this vessel, above and below the aperture, a needle armed with thread,
with the intention of making a ligature should it become necessary. A cushion
was placed upon the posterior part of the tliigh, opposite to the wound, ^which
was filled with a pyramid formed of pieces of agaric and compresses ; lint,
well sprinkled with colophony was also disposed round the pyramid in such a
manner as to support it, and it was kept in place by compresses and an ordinary
bandage. A few trifling hemorrhages occurred, but the patient eventually
recovered, and was able to walk at the expiration of two months.
Notwithstanding these happy results, obtained by surgeons of the highest
rank, the above mode of treatment ought to be proscribed from sound practice.
The only occasion to which its use is applicable is, when after having opened
an aneurismal sac it is impossible to discover the artery, a difficulty of which
Ave can scarcely conceive the possibility, and which, besides, could now
occasion embarrassment only in cases where the malady approaches too near
to the splanchnic cavities.
OPERATIVE SURGERY. 37
Another species of immediate compression, originating doubtless from the
observation of Desault, consists in pressing the artery, whether previously
open or not, with any appropriate instrument, and holding it flat until its sides
have become firmly united. Percy recommended for this purpose, in 1792,
a leaden plate; and afterwards, in 1810, a steel forceps, terminating in two
small plates, and furnished with a longitudinal slit, to enable the operator, by
meams of a button, to graduate at will the pressure exerted upon the artery.
In the same year, M. Duret, of Brest, constructed an instrument upon the
same principles. According to M. Roux, an instrument very nearly the same
as the above, was invented, in 1808 or 1809, by M. Levesque, who described
it in his Thesis.
A third compressive instrument, invented by Assaline, of Milan, formed
of two silver branches, joined like those of the dressing forceps, with a spring
between the handles, resembles very much the invention of M. Duret.
Assalini affirms that he has cured several aneurisms of the ham and thigh, by
leaving his instrument applied for only three or four days, or even 24 hours.
Other forceps and metallic instruments of diflferent kinds, have been since
invented to attain the same object, and will receive due attention hereafter.
Art. 4. — Cautery.
Two methods of cauterization have been practised for the cure of aneurism.
Some practitioners, indeed, before the discovery of the circulation of the blood,
had the temerity to apply caustics more or less powerful to the aneurismal
tumors, and to the skin which covered them. Others begun by opening and
emptying the cyst, and then cauterized the lacerated part of the artery with
a red hot iron, or with concentrated acids, or by introducing into the orifice
troches, or plup of alum, or vitriol. At that time also, and even since,
surgeons have in some cases contented themselves with filling up the whole
wound with lint or oakum, previously steeped in caustic liquids. Such means
might be tolerated at a time when surgery had made but little progress, when
the nature of aneurisms was unknown, and when scarcely any one possessed
sufficient anatomical knowledge to dare to make use of the bistoury ; now,
however, it is not permitted to speak of such methods, excepting to proscribe
them, and to show at what a distance modern surgery is from the ancient. .
It has been recently recommended to thrust a needle into the sac in such a
manner that it should pass almost through its cavity, and to attach to the
needle a metallic chain or rod, capable of transmitting to it an electric
discharge. I am not acquainted with any case that can be adduced in support
of this recommendation. I only know that M. Pravaz has attempted some-
thing like this by means of cautery, and that it is not unreasonable to suppose,
that by means, of such a contrivance as this we may in some cases occasion
the coagulation of the blood, and possibly even a resolution of the aneurism
Art. 5. — Ligature.
As the obliteration of the artery is indispensable, or nearly indispensable,
to the cure of aneurism, so the ligature is the surest and best means of
accomplishing that object. This is a truth which is not, nor ever has been,
contested. But to apply a ligature upon an arterv is a painful and sanguinary
operation ; it is necessary to divide susceptible tissues with a cutting instru-
ment ; hence the frequent attempts to discover other and milder means.
38 ^ NEW ELEMENTS OF
§ 1. Nature and Form of the Ligature.
Until of late surgeons had used ligatures composed of threads of linen or
hemp. A single thread was preferred for the small arteries, while for the
large trunks several threads were put together, and formed into a sort of
cord by means of wax. It appears, however, that the ancients made use of
silk. Guy de Chauliac says so positively. This was still the custom when
Scarpa and Jones subjected to the test of reason and experiment, what had
before been practised only by routine.
The first of these authors established the point, that in order to obliterate
the cavity of an artery it is necessary to bring its parieties into contact
without lacerating them, and to occasion adhesive inflammation. In accord-
ance with these views, Scarpa recommended the use of two fiat ligatures,
composed of six strands of thread ; and further, that there should be placed
between the ligature and the artery a small roll of cloth, six lines in length
and three in thickness ; this roll is spoken of by Pare, Platner and Heister, and
was used by almost all the Italian surgeons of the last century: also by Funchall
and Forster. The last substituted a small wooden cylinder, a quarter of an
inch thick and three-quarters of an inch long, which Saviard mentions as being
in general use in his time, but which Mr. Cline has since replaced by a bit of
coi-K. By these means the inner and middle tunics of the vessel are neither
bruised nor lacerated ; their contact is perfect 5 they unite firmly, even
before the separation of the two portions ot the artery has been effected by
ulceration under the cord.
According to Dr. Jones, the opinion of Scarpa is completely^ erroneous ; it
is not by the inflammation of their internal surface that the arteries are closed,
but rather by the effusion of coagulable fluid which follows the rupture of
their inner coats; consequently, instead of large and flat ligatures, with
rolls of linen or cylinders of any description, which more or less oppose this
rupture, Jones recommends the selection of such ligatures as shall effect it
the most easily and the most completely. Numerous experiments were made
by him upon dogs and horses, and all had results conformable to his theory,
which speedily assumed the form of a law with the generality of English
surgeons. To Mr, Hodgson the justice of the hypothesis of Jones seems so
evident, that he cannot comprehend how any practitioners dare still to make
use of the large ligatures and the little rolls of Scarpa. And it is not without
some degree of bitterness that Mr. Samuel Cooper reproaches the French
surgeons for being so slow to adopt the practice recommended by Jones, a
practice which has induced several of his countrymen to prefer the finest
possible threads ; threads of silk, of that gummed silk which dentists and
anglers use ; in short, threads so fine that when they are cut near the knot,,
as was done by Mr. Lawrence, there does not remain the 20th, or even the
46th part of a grain in the wound.
Without denying the importance of the labors of Dr. Jones, M. Roux
continued and still continues to use flat ligatures, which he generally ties
over a small roll of gummed diachylum. In support of this practice may be
quoted that of M. Boyer, of Scarpa, and even of the older surgeons ; for
Saviard speaks of the little roll in his treatise on surgery as a thing already
in common use. Mr. Crampton, in Ireland, has never done otherwise, and
has had no occasion for regret. He has even combated the doctrines of
Jones with such ability as to hinder them from being universally received in
the three kingdoms. M. Richreand endeavored to reconcile these conflicting
opinions, by remarking that a flat ligature becomes round in tying, and that
OPERATIVE SURGERY. 39
its application really resulted, like that of (he cylindrical ligature, in the
rupture of the middle and internal coats of the artery, which tends to
substantiate the doctrine of the practitioners of Great Britain. But in the
meantime comes Dr. Jameson, of Baltimore, in America, who by new experi-
ments, discredits the principal assertions of Jones. It is not true, says he,
that the rupture of the fragile tunics of the artery is advantageous ; on the
contrary, every exertion should be made to avoid it. Fine threads and round
ligatures are dangerous, because they cut the internal and middle membranes,
but above all, because they strangulate the vasa vasorum of the cellular tunic.
Yet he rejects every kind of foreign body, which some would place between
the vessel and the bandage, as well as all ligatures of thread of whatever form
or volume : strips of untanned deer skin appear to him to be infinitely prefer-
able in every case, since these ligatures possess an elasticity and flexibility
which will permit them gently to close and indent the artery without breaking
any of its coats, or lacerating the vasa vasorum, and which may be safely left
in the wound.
Another question naturally connects itself with this discussion. It has
been asked, if it would not be possible to substitute for threads of vegetable
substance cords formed of animal matter, likely to soften, to dissolve, and
be removed by interstitial absorption into the living tissues, without hindering
in any degree the immediate reunion of the divided parts. A series of
experiments of this description was made in London, in 1815, with silk.
One trial in the hands of Mr. Lawrence, and another in those of Mr. Carwar-
dine, met with all the success they could have anticipated. The incision
was enabled to cicatrize in the space of four, five, or six days, and the little
knot left on the artery occasioned no accident. But other experimenters
have been less fortunate ; either the immediate reunion has not taken place,
or there have been formed small purulent sacs, little abscesses which have
not been dried up until after the expulsion, or removal of portions of the silk
left in the wound. A patient on whom Mr. Lawrence himself operated on
the 29th of March, 1829, was not completely cured until the end of May.
Mr. Watson, after he had practised upon a patient this manner of tying the
humeral artery, saw the knot of silk tear open the cicatrix, and escape, at
the expiration of two months. The same thing occurred under the observ-
ation of Mr. Hodgson, at the end of six months ; and M. Cumin speaks of
a patient who retained this ligature for the space of two or three years. So
that, to sum up the whole matter, silk does not appear to be susceptible of
removal by absorption.
Sir A. Cooper has completely succeeded with a ligature of catgut. This
substance is much more easily dissolved than silk, and would be preferable
in every respect, if it were not necessary, in consequence of its slight power
of resistance, to allow it a considerable volume. On the first patient the
cure was completed on the twentieth day ; on the second, who was eighty
years of age, the incision required only four days to cicatrize, and in neither
case has the ligature ever reappeared. The same success however has
not crowned the efforts of Mr. Norman ; this physician twice tried the
method of Sir A. Cooper, and both times the cure was a long time de-
ferred. Mr. Wardrop, in some of his operations according to the method of
Brasdor, has made use of the intestines of the silk- worm, in the shape of
thread.
According to Drs. Jameson and Dorsey, Dr.Physick, of Philadelphia, was
the first to use ligatures of animal matter, in 1814; those which he prefers
are round, and made of deer skin or of catgut ; but, like Messrs. Lawrence
40 NEW ELEMENTS OF
and Cooper, he intended to cut or break the arterial coats, while Dr. Jameson
desires by all means to preserve them.
The surgeon of Baltimore allows to his deer skin ligatures the thickness
of two lines, and increases their strength and firmness more or less, by-
drawing them between the nails. When applied to the artery, these strips
need not be tightly drawn in order to efface its calibre, so that in spite of the
absence of a mreign intermediate body they produce the same effect as the
ligatures of Scarpa, without arresting like them the circulation in the vessels
of the cellular tunic. Dr. Jameson assures us, that after having been pulled
between the nails, these ligatures if tightly drawn can cut the arterial tunics
in the same manner as the flat ligatures of thread or silk, whilst in their
naturally soft and flexible state they are incapable of producing this eff*ect.
Dr. H. Levert, of Alabama, in America, has lately published results of a
different description. Having remarked that lead, gold, silver, and platina
but slightly irritate the parts with which they come in contact. Dr. Physick
first conceived the idea of fabricating ligatures of these metals. Dr. Levert
seized upon this proposition of Dr. Physick, and subjected it to several
experiments. He made five upon the carotid artery of a dog with leaden
threads strongly fastened, then cut very close to the knot, and left at the
bottom of the wound. Immediate reunion has been obtained at the expiration
of the 17th, 18th, 19th, 28th and 42d day; the vessel has constantly been
found to be obliterated, and the little circle of lead enclosed in a cellular cyst
more or less dense. Three experiments on the carotid, and two- on the
femoral artery, with gold wire, three others on the femoral, and the two
carotids with silver, and three on the carotid with platina, have produced
exactly the same effects as the ligatures of lead. Dr. Levert has arrived at
similar results by the use of ligatures of waxed silk, of gum elastic, and
even with blades of grass.
From these inquiries it results, as I conceive, that the nature and the form
of the ligatures in the treatment of aneurisms, are not so important as they
have been generally thought for the last thirty years, and that the French
suro;eons were right in this pomt of view, in not adopting precipitately, and
without reserve, the consequences deduced in England from the experiments
of Jones. The large ligatures of Scarpa cause too much irritation in the
wound, produce a too extensive suppuration, and require too long a time to
elapse before they can be withdrawn, to merit an exclusive preference. Thi»
I think cannot be denied; but it is equally true that, by flattening the artery
without bending it, they hold the parietes in perfect contact, without neces-
sarily cutting the vasa vasorum. The cellular tunic becoming inflamed under
such pressure, soon transmits its or2;anization to the two other arterial mem-
branes, and the whole, being speedily blended, form one impermeable cord.
The reproaches of Mr. Hodgson, then, are far from being perfectly well
founded. When a fine ligature is used in order to break more surely the
internal and middle tunics, you compress, at the same time, as is contended
by Dr. Jameson, the small vessels of the external membrane, and it is not,
as advanced by Jones, by the interior infusion of organizable lymph that the
obliteration of the artery is principally effected. On the contrary, the liga-
ture is itself promptly enveloped with a coagulable fluid, the continuity of
the small vessels which had been broken is quickly re-established on its
external surface, and it finds itself at last in the centre of an organized
ring, analogous to that which has been imagined by Duhamel, in the
formation of callus for the union of fractured bones. This albuminous
ring, the mechanism of which has been followed up by Dr. Pecot, with great
OPERATIVE SURGERTJI 4T
care, in observations on dogs, hardens by degrees, contracts upon itself, and
is gradually confounded with the two occluded ends of the artery, after the
removal of the ligature. Messrs. Scarpa, Crampton, and Jameson, were then
wrong in attributing to fine ligatures a greater tendency to produce secondary
hemorrhages than to the flat or large ligatures.
As to ligatures composed of animal substances, it is incontestable that in
permitting the incision to close immediately they may be of very great service
in practice. It remains to be seen what should be their exact form or nature.
If it is desired that thev should be very fine, silk alone should be employed,
but unfortunately we have seen that this substance will not yield to the
interstitial action of the organs — catgut has not the same solidity, nor is it
very easily absorbed. Straps of deer skin, which are easily dissolved and
possess great elasticity, promise greater advantages, but before adopting
them, surgery demands new experiments, and that the results mentioned by Dr.
Jameson shall be confirmed by other practitioners. Admitting that when
left about the artery these cords do not act as foreign bodies, that the system
may be able to appropriate them and will not be obliged, sooner or later to
remove them, there is no person who cannot comprehend at a glance the
services which they may render to invalids. With them the plastic ring,
indicated M. Pecot, would be complete ; free from all perforation or inter-
ruption, it would be sustained by the exact apposition and immediate reunion
of the parts, and would incur no risk of being destroyed by suppuration, or
lacerated by the removal of the thread. For the rest, whether the ligature
be a little larger or a little smaller j whether the internal and middle tunics be
or be not broken ; whether the vasa vasorum be more or be less completely
strangulated, I believe that the definitive results will nevertheless be very
much the same.
§ 2. Permanent Ligature.
A ligature formed of vegetable materials, tied tightly enough to intercept
the passao-e of the blood in an artery, is a foreign body which will not retire
from the incision until it have cut the cord which it encircles. It is neces-
sary, then, in order that hemorrhage may not follow its removal, that the
vessel should have had time to close itself firmly, both above and below,,
otherwise the albuminous virole which surrounds it not being of sufficient
consistence to resist the blood, and being already open towards the skin,,
would be immediately swept away. If the ligature, as has been generally
believed, produce only adhesive inflammation in the circle of the vessel whicli
it immediately embraces, there would be nothing to fear from the separation,
for before it can divide the artery must of necessity be inflamed. But the
experiments and reasoning of M. Pecot tend to prove that this is not the case ;
that the portion of the vessel inclosed by the loop of the ligature almost neces-
sarily mortifies, whatever may be the degree of constriction which it sustains,
and that it is only by an eliminating process, analagous to that which takes place
in other instances of gangrene, that it is detached from the surrounding tissues.
When this process is not deranged, and when the organic elements upon
which it is effected are in the normal state, and where nothing intervenes to
prevent the establishment of adhesive inflammation, the ligature is not removed
until from the eleventh to the twentieth day ; and since by the fourth or fifth
day the superior extremity of the arterial canal has become impermeable,
there is on this point no occasion for anxiety. But if unhappily the parietes
of the vessel are soft, steotamatous, yellow, or inflamed, the ligature will
6
42 NEW ELEMENTS QF
have mechanically divided them ; if the channel is not completely closed,
they will ulcerate without interrupting the current of the blood : and again,
if they are hard, and incrusted with calcareous concretions, as they frequently
are in aged persons, it is easy to see that the inflammation which can be
excited in them will be most frequently of too low a grade, and too irregular
to occasion the necessary effusion of concrescible material, either on the
exterior or the interior, and that however long deferred, the coming away of
ligature may produce a serious hemorrhage.
§ 3. Precautionary Ligature ^
In order to obviate such unfortunate results, have been invented precau-
tionary ligatures : that is to say, cords which only become useful in case that
which has been first applied has effected the division of the artery before it
has been perfectly obliterated. One of these ligatures was carried round the
vessel without being tightened, a few lines below the principal ligature; a
second, composed of two separate strands, was placed a little above the
inferior portion, to be tied in such a manner as not to close up the arteries,
but only to deaden the impulse of the column of blood against the point
which it is intended to obliterate ; a third, also double, was placed still higher,
and this latter, the same as the superior strand of the preceding, was left
loose. In case the fixed ligature should fail, the first pair of the uppef
precautionary ligatures would be tied, and subsequently, in case of need, all
tlie others, in order to stop the hemorrhage.
The same was done with the two portions of the inferior ligature, which
has no other object than to oppose the reflux of the blood through the incision.
This was the reasoning and the practice of A. Monroe, Guattani, Hunter,
Desault, Deschamps, Pelletan, and even for some time of Mr. Boyer. At
this time, precautionary ligatures have almost entirely disappeared. So far
are they from being considered useful, that they are denounced as being very
dangerous; they were at first reproached, and justly, with irritating the
incision too highly, with continuing suppuration, and with opposing an in-
surmountable obstacle to immediate reunion. Besides, Messrs. Dupuytren
and Beclard have demonstrated, that during the inflammation, the pofnt of
the vessel near which they lie assumes a fatty consistence, is extremely
easy to cut, and entirely incapable of supporting the action of any ligature
whatever ; whence it follows, that their mere presence is enough to occasion
the ulceration of the artery, which they divide with the same facility as lard
or cheese, as soon as it is necessary to exert the slightest farce in the way of
constriction.
§ 4. Temporary Ligature,
Not only have the precautionary ligatures been rejected, but it has been
inquired whether it would not be possible, without affecting the success of the
operation, to remove the only ligature which may be employed before it has
had time to cut the vessel. It is near thirty years since the examination of this
question was began in England. Jones is said to have found, that in breaking
at three or four points at some distance from each other the internal and
lesser coats of an artery, with as many fine threads, a lymphatic effusion
was produced which was sufficient to determine the obliteration sought for,
and permitted the removal of the ligatures in a few minutes. The results
obtained by Mr. Hutchinson fully confirm those of Jones ; but Dalrymple,
Hodgson, and Travers, have been less successful. Their experiments have been
OPERATIVE SURGERY. 43
tried upon horses and sheep, and the artery has never been found obliterated.
It was only slightly contracted when the animal was killed, after the lapse of
IS, 15, or 18 days. Mr. Travers, however, thought that this suggestion,
might be rendered available by a slight modification. Instead of removing
the ligature immediately after having closed up the artery, he resolved to leave
it tied until sufficient time should nave elapsed to permit the clotted blood
and the lymphatic effusion to acquire a certain degree of firmness and consist-
ence, which would render it capable of resisting the force of the blood. His
experiments upon horses have led him to the conclusion, that a ligature continued
for six hours, two hours, or even one hour, upon the carotid, will commonly result
in a permanent obliteration of the arterial canal. In 1817, he applied a ligature
upon the brachial artery of a man, and withdrew it fifty hours afterwards
without the pulsation being restored in the tumor. Mr. Roberts has gone still
farther ; a ligature which he left only twenty-four hours on the femoral artery
of a sailor affected with popliteal aneurism^ was sufficient to effect a complete
cure in twelve days.
In repeating these experiments, unfortunately the same successful results
have not always been obtained. Mr. Hutchinson has seen the circulation
immediately re-established in the femoral artery, although it had been firmly
tied with a ligature for the space of six hours. The same thing has occurred
to Sir A. Cooper, after thirty-two and forty hours. Mr. Travers himself,
upon withdrawing the thread which he had left upon the artery of the thigh for
twenty-five hours, has seen the pulsation reappear by degrees in the aneurism,
refuse to yield to a long-continued mediate compression, and occasion the
necessity of at last applying a ligature in the ordinary way, so that he finally
relinquished this practice, which the experiments of Beclard had prevented
from being adopted in France.
At the very time when the temporary ligature lost its warmest partisans in
London, the surgeons of Italy took it up. Scarpa subjected it to new trials, and
endeavored to establish it in general practice. Flat ligatures tied over a small
cylinder of waxed cloth upon the carotid arteries of several sheep, and
withdrawn on the third, fourth, or fifth day, always produced the complete
obliteration of the cavity of the vessel. These experiments being repeated
on horses by M. Mislei, veterinary surgeon at the school of Milan, produced
exactly the same results. Upon the human body the success of this practice
has not been less happy. Paletta communicated to Scarpa two remarkable
examples. The first subject was a man of forty, who had been affected for
two or three months with an aneurism in the ham. The ligature was applied
upon the femoral artery on the 8th of January, 1817, and removed on the 12th.
The second instance relates to an invalid, sixty years old, with an aneurism in
the bend of the arm ; a ligature placed on the humeral artery was withdrawn on
the fourth day, and, as in the case of the first individual, the operation resulted
in success. A popliteal aneurism, treated in the same way by M. Biraghi,
had the same termination. The same is true of a fourth individual, on whom
the humeral artery had been opened, and who had applied for assistance at
the hospital of Pavia. Messrs. Molina, Fenini, Maunoir, Wattmann, Fitz,
Medoro, Solera, Roberts, Falcieri,Uccelli, Giuntini, and Malago, have also used
the temporary ligature with success in the treatment of aneurisms of the carotid
and femoral arteries. Vacca objected, that after the removal of the ligature,
the artery is, notwithstanding, sooner or later divided. The experiments of
M. Pecot, opposed to those of Mr. Seller, tend to confirm this opinion, whicli
nevertheless, takes nothing from the weight of the facts and reasonings of
Scarpa.
44 NEW ELEMENTS OF
Operative Processes.
The difficulty, as is shown in a case related by Mazzoni, consists in
removing the ligature, without drawing upon the artery or disuniting the lips
of the incision. Viewed in this light, all the means employed in England
appear faulty. The two single threads previously laid by Messrs. Paletta
and Roberts between the vessel, or the little roll and the tape which serves
as a ligature for the purpose of untying the latter in drawing them out, eff'ect
the object but very imperfectly. The same may be said of the bit of a
grooved director which M. Uccelli tied in the same tape with the roll of cloth,
and upon which he proposed afterwards to cut the knot. M. Giuntini con-
tents nimself with attaching to the end of the cylinder, or roll, before it is
fixed upon the artery, a waxed thread, by which it may afterwards be with-
drawn so as to render the cutting of the ligature more easy. For all these
modes Scarpa substituted the following : —
1. Process of Scarpa. — A grooved probe, notched at its extremity, and
furnished with two small flat rings on one edge, the oneabouthalf a line from
the point, the other about an inch from the handle, serves to conduct a very
small knife down to the ligature where it surrounds the artery ; the mode of
using this little apparatus is very simple. The end of the ligature which has
been kept outside, is successively passed through the two rings which are
intended to receive it. The beak of the director is then carefully directed
to the little roll of linen which arrests its progress ; the knife then penetrates
as far as the ligature, which it cuts across, and which can then be withdrawn
without the least danger to the vessel. For further details of this ingenious
process, consult the article inserted by M. Ollivier in the second volume of
the Archives Generates,
2. Process of Deschamps. — In France also, some attempts have been made
with the temporary ligature, but after a different manner ; that is, in combi-
nation with immediate compression. In 1793, Deschamps invented his presse-
artere, that is to say, an instrument composed of a flattened metallic wire,
about three inches in length, notched at its free extremity, and terminated at
the other by a horizontal plate resembling the head of a nail, flat, rather long
than wide, and pierced with two slits near the edges. The operation is
commenced by passing the ends of the ligature, which has been placed under
the vessel, through the two holes in the instrument. The surgeon then draws
upon these, and at the same time presses down the head. Thus the trunk of
the vessel is held flat, between the tape and the flat extremity of the presse-
artere ; the one drawing it forwards, and the other pressing it backwards.
Lastly, the ends of the ligature are fastened upon the notch of the instrument.
The small canuli used by Assalini, the compresses tried or recommended
by Forney, Flajani, Buzani, Garnery, Ayzer, Crampton, Ristelhueber, Deaze,
and others, although differing in some respects from that of Deschamps, have
yet been all constructed after the same idea ; that is to say, with the intention
of flattening instead of pursing up the vessel, and of withdrawing the ligature
at a given time. Like it also they are attended with the inconvenience of
irritating tlie wound, and of promoting the ulceration of the artery, which they
too often but incompletely close.
3. New Process. — If any just conclusions may be deduced from experi-
ments made upon dogs, the following process will prove to be means as easy
of employment as certain of success, for obtaining by means of temporary
ligatures the obliteration of arterial canals. A common pin is passed under
the artery, the two extremities of which are then encircled by a loop of thread.
I
OPERATIVE SURGERY. '^^ 45
as in the twisted suture, which is made sufficiently tight to prevent the passage
of the blood. A second thread attached to its head, allows the removal of
the pin whenever it is thought expedient. The ligature thus released, no
lono-er oifers the slightest resistance, but drops out almost of itself. The
process employed by M. Malago, and which consists in twisting the two heads
of the ligature instead of tying them, would be more simple, it is true, but
it would not possess the same degree of certainty.
4. Process of M, Dubois. — The idea which suggested to Deschamps the
construction of his presse-artere, that is, of obliterating the vessel only by
degrees, was adopted by M. Dubois, who endeavored to found upon it a new
method of treating aneurism. In 1810, after having placed the ligature around
the artery, this practitioner then passed the extremities through the serre-ncBud
of Desauit, in such a manner as to gradually intercept the course of the blood,
and only to effect the complete obliteration of the arterial calibre after six or
eight days. His intention in following this plan was to permit the supple-
mentary branches to dilate gradually, and to prevent the gangrene, which at
that period was thought to be a necessary consequence of suddenly tying a
large artery. The two instances of success mentioned by M. Richerand, and
which were obtained by this process at La Clinique de la Faculte, at first
forcibly attracted public attention ; but a third attempt being followed on the
fifteenth day by a hemorrhage, which required the amjifutation of the limb,
and finallv caused the death of the patient (although the pulsations had
ceased to be discoverable in the tumor by the tenth day), soon put an end to
these gratifying expectations. Since then (the close of 1810), I have no
knowledge that recourse has been again had to this mode of procedure,
notwithstanding the two successful cases of MM. Viricel and Larrey. Now
that we are able to set a just estimate upon the dangers of suddenly
suspending the circulation in the principal artery of a limb, a process of that
nature has deservedly lost all value, and what I have said concerning the
precautionary ligatures, is enough to shov/ that they are the most dangerous
contrivances which can be proposed.
§ 5. Two Ligatures with intennediate division of the Artery.
Galen, Aetius, Celsus, Guy de Chauliac, Rufus, Rhazes, Gouey, Severin,
and others, were in the habit of applying two ligatures at some distance from
each other, and then dividing the artery between them. Pelletan, following
the suggestion of Tenon, was upon the point of imitating this practice, which
had been completely forgotten about the close of the last century, and which
Heister, Callisen, and Richter, have strongly reprobated. Abernethy adopted
it for his first ligatures on the external iliac artery, not knowing that his coun-
trymen Bell had already spoken of it, but believing himself to be the inventor.
\Vith this .precaution, says he, the two ends of the artery are retracted into
tlie flesh, without being subjected to any dragging, and are in the same condition
as in the case of amputation. M. Maunoir, who published in 1802 a treatise
on this modification, w^hich he also regarded as his own, has declared himself
its defender. With Morand, he concedes to the arteries a great retractile
power ; believes that in pursing them up the circular ligature shortens them,
disposes them to be violently pulled by the impulse of the heart at the throb
of every pulsation, and that the best means of preventing secondary hemor-
rhage, is to permit the artery which has just been tied to retire into the soft
parts as far as its natural retractility requires. Some facts cited by Messrs.,
Abernethy, Black, A. Cooper, Maunoir, Dairy mple, Post, Guthrie, and others.
46 NEW ELEMENTS Ot
seemed at first to confirm the elij^ibility of this method, which Messrs. Roux,
Larrev, Lisfranc, and Taxil, in France, were very much disposed to adopt, at
least for tlie great arteries. But on being tried in 1807, by Mr. Norman, of
Batli, it gave rise to a very troublesome hemorrhage, and Scarpa, who, con-
demning it, advances the observations of Monteggia, Assalini, and others, when
it was attended with fatal hemorrhage.
It is certain that the reasonings on which they rely in dividing the arteries
between the two ligatures, are ill grounded. The retractility imagined by
Morand and M. Maunoir, and upon which Messrs. Beaufils, Taxil, Saint
Vincent, and more recently Mr. Guthrie, have so earnestly insisted, scarcely
exists, as has been proved by the experiments of Beclard, and as I have several
times been able personally to convince myself. If after the amputation of
limbs the arteries retire sometimes very far, it is because they are drawn away
by the muscles and not by any contractility inherent in themselves. Then
even supposing that being indented by a ligature they undergo some stretch-
ing, nothing is more simple than to pick an end to this without breaking the
continuity of any tissue. It is sufficient for that purpose to follow the advice
given by Lyng, that is, to place the member in a semiflexed position, and all
the muscles in a state of relaxation. Not only is there no appreciable advantage
to be gained from this division of the artery, but it also exposes you to the
greatest danger. If the ligature of th€ superior extremity of the artery for
example, should get loose, or should become relaxed, as has happened in the
practice of Messrs. A. Cooper and Cline, an alarming hemorrhage will of
necessity result, capable of becoming quickly mortal if the patient is not
instantly relieved. Should a similar accident happen after ligature of the
carotid artery in the inferior region of the neck of the subclavian, or of
either of the iliac arteries, death will be the almost inevitable consequence.
We must then conclude that the advice given by Abernethy and Maunoir, to
place two ligatures on the great arteries and then to cut the vessel in the
interval, is a method dangerous in its consequences and of no avail in regard
to the end proposed.
§ 6. Ligature through the Artery*
For some time past there has been an endeavor to bring forward a process
mentioned by Dionis, and described by Richter in the following terms : — " The
artery," says he, ♦* after having been drawn to the outer side, should be encir-
cled twice with an ordinary ligature, which should be fastened by a knot, and
when the artery is of any considerable size, one of the ends of the ligature should
be passed through it by means of a needle. It is this manner of operating which
Cline thought proper to recommend, in order to prevent the ligatures used
after the manner of Maunoir from relaxing and slipping from the ends of the
artery. Sir A. Cooper made trial of it upon a subject twenty -nine years of age,
in operating for an aneurism in the popliteal region. The two ligatures were
first tied at the bottom of the inguinal region ; the needles were then passed
through the coats of the vessel between the two ligatures, and the ends of both
the threads were then attached to the knots of the first ligatures, with the
intention of preventing the possibility of slipping. Mr. S. Cooper, and all
other surgeons, have condemned this procedure, and I think with reason, for
it has neither analogy nor experience in its favor, nor couldany thing justify
its employment. Yet it may have given birth to that operation which Dr.
Jameson appears to have practised several times with success. This phy-
sician thougnt that to transfix a large artery or vein with a seton, two or tnree
OPERATIVE SURGERY. 47
lines in size, would be sufficient to determine its obliteration ; the experiments
made by him on the carotid, and jugular veins of horses, have always produced
an effusion of plastic lymph in the interior of the vessel, a thickening of the
divided parietes, and soon after a complete interruption of the course of the
blood. I learn from Dr. Chumet, of Bordeaux, that these experiments having
been repeated at Val-de- Grace, gave the same results. From a communica-
tion of M. Carron du Villards, it appears that he too has made experiments
on animals, which demonstrate that the same end is obtained by piercing the
artery with a linen thread or with a wire of iron, steel, or silver, &c. so that
a new question here presents itself, which in my view merits the attention of
practitioners. A strip of skin, or a conical wire, or shank of some metallic
substance, being left at the extremity of the wound, would not in any degree
hinder its immediate reunion, and would render the operation for aneurism
exceedingly simple, if the cure would as surely follow this method as it does
tlie application of the ligature,
§ 7. Mediate Ligature,
The ancients, not possessing the necessary anatomical knowledge, did not
give themselves the trouble ot finding the artery, but contented themselves
in some cases with piercing the whole thickness of the limb between the
vessel and the bone, and then tying up the two ends of the cord over a
compress placed between the ligature and the skin. This is the process
recommended by Thevenin, and the process which Le Dran and Garengeot
did not disdain to follow in the beginning of the last century, in order to
suspend the circulation of the brachial artery whilst they amputated the
shoulder. Although surgeons may sometimes have succeeded by this absurd
method in the cure of aneurism, I do not think it necessary in our day to
discuss it at greater length to point out its disadvantages and its dangers.
§ 8. Immediate Ligature.
On proceeding to search for the artery at the bottom of the aneurismal sac
or bag, it was sometimes so difficult to isolate it from the surrounding tissues,
that the question arose whether it would not be right at the same time to
comprehend within the ligature the accompanying veins, or nerves. —
Molinelli sustains that it is useless to take so many precautions, and that
the inclusion of the great nervous cords rarely effects the success of the
operation. Thierry has arrived at the same conclusions, after having made
sundry experiments on dogs, sometimes tying up the axillary and femoral
artery without touching the nervous plexus, and sometimes including it with
the thread, and no case whatever resulted in either gangrene or permanent
paralysis. The moderns, nevertheless, have rejected this practice, and
consider that, except in cases of insurmountable difficulty, the artery alone
should be confined by means of the ligature. An observation is extracted by
!Pelletan from a letter of Testa, in which it is seen that a patient, treated by
Falconnet, who had included in the same ligature the nerves, the vein, and
the popliteal artery, was immediately seized with horrible pains in the limb,
which mortified in the evening of the same day. Even if this case will not
compel us to conform to the practice of modern surgeons, reason itself, unas-
sisted by such dreadful experience, should suffice to bring us to the same
result. It may indeed be conceived that the division of one or more of the
-48 ■* NEW ELEMENTS OF
nerves of a part will not necessarily produce paralysis: and it may be
conceived, too (notwithstanding the opinions of Mr. Guthrie), that the liga-
ture of a great vein need not of course be attended with gangrene, but if both
these kinds of organs be included in a ligature at the same time with the
principal artery of the same limb, it cannot be doubted that mortification and
loss 01 feeling must take place, if not always, at least in the greater number
of cases. It is evident besides, that in advising us to pay no attention to
organs of smch importance, tlie surgeons have desired to justify their want
of care in isolating the artery. At the present day it is customary to exclude
from the ligature every vein, and every the smallest nervous cord, and every
particle of the surrounding tissues ; and this practice is, without doubt, one
of the reasons why the operation for aneurism, heretofore so formidable, is
now so simple and so easy.
Since precautionary ligatures have been rejected, some persons have
tliought, that for greater security it would be well to apply upon the great
arteries two ligatures at some distance from each other. Vacca observes that
nothing is gained by this procedure, inasmuch as the portion of the vessel
between the two ligatures necessarily gangrenes. But this reason of the
Professor of Pisa cannot now have weight ; for Mr.Briquet reports, upon tlie
authority of Beclard, that a segment of artery may very well continue to live,
although it have no longer any communication with the trunk from which it
has been separated. It should then be for other reasons that we proscribe
the double ligature.
Art, 6. — Methods of Operation,
A. Aetius says, that in order to cure aneurism you must expose the artery
above the affected part, tie it in two places, then cut across, open, and empty
the aneurismal cyst; raise the vessel, tie it above and then below the opening,
and cut it a second time across.
B. Paulus ^gineta speaks of a process which consists in passing, by means
of a needle, a double ligature behind the centre of the aneurism, to bring back
one of these ligatures to the upper, and the other to the lower part of the
tumor, which is thus strangulated above and below. It is then opened and
almost completely removed. Thevenin also mentions this process, which is
evidently nearly the same with that formerly employed for the removal of
wens, and several other tumors. It is to him, no doubt, that Guy de Chau-
liac refers, when he asserts that aneurism can be cured by employing the
ligature, a mode de rompure.
C The last-mentioned author describes another method, which although it
approaches that of Paul of Egina, would yet seem to differ from it in some
respects, and in reality to be more rational. *' It is necessary," says he,
** tliat the artery should be exposed in both directions, and tied with the thread ;
the f)art remaining between the two bands should be cut, and then treated in
the same manner as ordinary incisions." The process so elaborately described
by Bertrandi, about the middle of the last century, being nothing more than
a repetition of that of Guy de Chauliac, does not deserve further notice in
this place. It is, besides, so far from being new, that even Philagrius had
had recourse to it.
D. Guillemeau,the competitor and disciple of Pare, simplified the method of
the ancients. He contented himself with tying the artery above the tumor,
opening the latter, removing the coagula, and then dressm^ it as a common
wound. This formed the basis of the old method of treating aneurisms ; a
\
OPERATIVE SURGERY. 49
method which, until the last century, was never applied except in cases of
aneurism of the bend of the arm.
E. Keisleyre, a surgeon of Lorraine, in the Austrian service, is the only
one who, about the year 1644, had ventured to practice it several times for
popliteal aneurism. Instead of beginning with the exposure of the artery
above the tumor, Keisleyre, after having suspended the course of the blood
in the member, by the assistance of the garot or of the tourniquet, opened
the whole length of the aneurismal bag, cleansed it carefully, sought out
the opening in the artery, introduced by it the end of a sound, so as to
raise the trunk, tied its superior portion, compressed the inferior, and then
treated the wound by the customary means. A century after the time of
Keisleyre, Guattani, Molinelli, Flajani, and almost all the surgeons of Italy,
employed the same method, which was not long of being generally adopted in
France, Germany, and England, after having undergone at difterent times
some slight modifications.
F. Instead of merely compressing the inferior extremity of the artery,
Molinelli, Guattani, and others, found it most prudent to encircle this too
with a ligature. The two Monros, Hunter, Desault, Pelletan, Deschamps,
and Boyer, believed that it would also be useful to leave some threads above
and below the former, to be used in case of necessity to arrest consecutive
hemorrhages. Hence arose the use of the precautionary ligature, which has
been already discussed.
G. A method diiferent from this last, and of which the elements are found
in Aetius and Guillemeau, was introduced into practice in tke beginning of
the last century by Anel. Having to treat an aneurism on a missionary of
the Levant, on the 30th of January, 1710, Anel applied, in the presence of
Lancisi, a simple ligature to the humeral artery immediately above the tumor,
without touching the cyst. On the 5th of March following the patient was
cured. Nevertheless, this result, however remarkable, did not at first attract
attention, and was not rescued from oblivion until somewhere between 1780
and 1786, when Desault endeavored to bring it again into notice in the
month of June, 1785. He tied the popliteal artery without opening the
aneurismal sac. On the 19th day a large quantity of matter mixed with blood
escaped from the wound, and in a short time after, the cure appeared to be
complete ; but the patient sunk about the seventh or eighth month.
According to M. Martin, of Marseilles, Professor Spezani had conceived,
early in the year 1781, the project of tying the femoral artery without
touching the sac, in cases of popliteal aneurism. In the month of December,
1785, Hunter carried this project into execution. His operation, being
completely successful, caused a great sensation in the surgical world, and was
really the signal of an entire revolution in the theory of the treatment of
aneurisms.
After this period the method of Anel has been described as the " new
method," the " modern method," the *' method of Desault," or of ** Hunter,"
neither of which denominations is justly applicable, and all of which should
yield to the name of " the method of Anel," its actual inventor.
H. A last method has just been introduced into the science. Arrested by
the difficulty or the impossibility of applying a ligature betwixt the aneu-
rism and the heart, and by the dangers of opening the sac when the disease
is situated too near the trunk, yet unwilling to resort to the method of
Valsalva, or to topical refrigerants, some surgeons have thought it feasible to
tie the vessel between the tumor and the capillary termination of the artery.
According to M. Boyer, it is to Vernet, a military surgeon, that we should
7
50 NEW ELEMENTS OF
ascribe the suggestion of this idea, since he first tried the compression of the
femoral artery below an inguinal aneurism. Brasdor is not the less the first
who formally proposed to place the ligature in that situation. Desault after-
wards advised the same method, and Deschamps put it in practice in the
case of a very voluminous aneurism in the bend of the arm, which threatened
to burst. The palpitations soon became much stronger in the tumor, which
it was found necessary in a few days to open very freely, and the patient
died in consequence of this operation, after having lost a considerable quantity
of blood. From that time the proposition of Brasdor seemed to have been
definitively condemned, was pronounced to be absurd, and was generally
rejected as dangerous. The experiment of Deschamps seemed to confirm
fullvthe fears which had been suggested by reasoning a priori. It had been
saicf that upon tying the artery on that side of the cyst, the blood being
arrested at this point by an insurmountable obstacle, would distend the
aneurismal tumor with more violence than ever, render the parietes thinner,
and finish by bursting a passage through them. But Sir Astley Cooper,
convinced, like Brasdor, that the circulation when suspended in the artery
below the tumor, would turn aside by the collateral branches, to return
through the inferior portion of the limb, but would stagnate and occasion
coagula in the tumor itself, and all that part of the vessel which lay between
the ligature and the first considerable branch given oft* in the direction of the
iieart, thought it not right to yield to the above reasoning. With these views
he ventured in 1818 to repeat the experiment of Deschamps on an aneurism
which pushed upwards Poupart's ligament, and appeared to occupy a great
part of the iliac fossa. The pulsation in the tumor continued, but the progress
of the disease was arrested. At the expiration of some time, the tumefaction
of the neighboring parts disappeared ; the coming away of the ligatures was
not followed by any accident; the wound cicatrized, and about the sixth
week he sent the patient to pass the period of convalescence in the country.
They learned afterwards that the tumor had broken, and that the man had
expired about two months after the operation : the body was not opened.
Notwithstanding this unfortunate result. Sir A. Cooper's operation was still
capable of exciting some hope, and of giving rise to new experiments. M.
Marjolin, in 1821, says, that before this method should be entirely abandoned,
new experiments ought to be made, particularly on the primitive trunk of the
carotid. M. Pecot has positively advised its adoption (since 1822), in
certain cases of aneurism of the primitive and external iliac arteries, and even
of the subclavian, when the volume or the disposition of the tumor prevents
the exposure of the artery, by the method of Anel ; the collateral branches
which may exist between the principal ligature and the sac, should be at the
same time secured. M. Casamayor also says, in his thesis (in 1825), after
having reviewed the facts and arguments cited for and against the method of
Brasdor, that it may be employed with success in cases of aneurism, where it
is possible, by this means, to suspend the current of the blood, or to reduce
its column to a size insufficient to prevent the contraction of the tumor. M.
Dupuytren has long said, in his lectures at the Hotel Dieu, that the partial
success obtained by Sir A. Cooper should incite rather than repress the zeal
of surgeons, and that by restricting the patient to a close regimen, and dimi-
nishing the mass of the fluids by frequent blood-lettings, either before or after
operation, its success would, in all probability, be favored. Things were in
this state, when, in spite of the reasonings of A. Burns, Hodgson, and many
other English authors, Mr. Wardrop, in 1825, resorted to the method of
Brasdor in a case of aneurism of the primitive carotid. This operation was
OPERATIVE SURGERY. 51
performed on a woman seventy-five jears old, on whom the tumor, being
situated close to the sternum, would not permit the passage of a ligature
between itself and the heart. On the fourteenth daj^ the aneurism was
diminished one half; pulsation in it ceased, and it at last broke and emptied
itself like an abscess. The ulcer was promptly cicatrized, and the patient
recovered.* In the course of the same year, Mr. Wardrop had occasion to
treat another woman, aged fifty-seven years, for an aneurism situated exactly
under the sterno-mastoidean muscle of the right side. On the 10th of December,
in the presence of Mr. Lawrence, the carotid artery was tied with a ligature
formed of the intestines of the silk-worm; on the 13th the wound was found
to be entirely closed, and on the 21st the patient was believed to be entirely
cured. She sunk on the 23d of March following, but with all the symptoms
of hypertrophy of the heart, and of accidents which could not be said to have
any connection with the operation itself. On the 1st of March, 1827, Mr. J.
Lambert, of Walworth, took occasion to imitate Mr. Wardrop, in a case of
aneurism of the right carotid, on a woman of forty-nine years of age. On
the third day the tumor had greatly decreased in size, and presented only
slight pulsations. On the tenth day came on a hemorrhage, which, how'-
ever, did not prevent the wound from closing. The tumor soon after
disappeared. On the 17th of April the cicatrix opened, and a fleshy lump
was found to occupy the centre. On the 18th a new hemorrhage occurred ;
was several times repeated between that day and the 30th, and on the 1st of
May became so abundant that the patient expired.
On examination of the body, it was perceived that the carotid artery was
ulcerated above the ligature ; that the aneurism was entirely obliterated, and
that the hemorrhage was attributable to the reflux of the blood from one
carotid artery through the other. Mr. Bushe, of New York, performed, on the
11th of September, 1827, a similar operation on a woman, thirty-six years of
age, with complete success. Mr. Wardrop practised it for the third time, on
the 6th of July of the same year, on a lady of forty-five years of age. On this
occasion, he tied the subclavian artery instead of the carotid, which was not the
seat of any pulsation, and which appeared to be obliterated. One month after
the patient left London, in order to recruit her strengtli in the country, and
towards the end of August was completely restored. Various symptoms of
disease in the chest afterwards occasioned some uneasiness: on the 9th of
September, 1828, her health was as good as it ever had been ; yet she died on
the 13th of the same month, in 1829. On the 2d of July, 1828, Mr. Evans,
of Belper, in his turn, operated, upon the plan of Brasdor, upon a patient aged
thirty years, for an aneurism of the trunk of the carotid artery, and on the 28th
of October the patient returned to his usual avocations. The disease after-
wards reappeared, and it became necessary to perform a new operation ; to tie
two tumors and excise them. The patient was finally cured. (Letter of Mr.
Evans to M.Villardebo, May, 1831.) A negro, treated in the same manner, on
the 10th of March, 1829, by Mr. Montgomery, of the island of Mauritius,
appeared to have been cured, but died on the llth of July following. Dr.V.
Mott lost a patient on the 22d of April, 1830, upon whom he had operated on
the 20th September, 1829, and whom he had believed to be cured. A woman
operated upon by Mr. Key, expired during the course of the same day.
Lastly, an attempt of the same kind was made on the 12th June, 1829, at the
Hotel Dieu, by M. Dupuytren, in case of an aneurism at the origin of the
right subclavian artery: the patient died on the ninth day after the operation,
* Was it really an aneurism ?
52 NEW ELEMENTS OF
rather, perhaps, in "consequence of profuse hemorrhages than immediatelj
from the operation itself. Messrs. White and James, who have imitated Sir
A.Cooper, have not been more successful. There are then, these three
methods of treating aneurism by ligature; and it only remains to be de-
termined which should be generally preferred, and in what cases it will be
advisable to have recourse to the other two.
Relative value of the three principal methods.
By the old method, or that of Keisleyre, it is necessary tliat tl;e situation of
the tumor should permit the introduction, between it and tl.e heart, of a
sufficient compression to suspend for a time all circulation in the limb. The
opening of the sac requires very extensive incision ; involves a large suppu-
ration ; renders the isolation and the ligature of the artery sometimes very
difficult ; frequently requires the thread to be placed on a part of the artery
more or less diseased ; especially exposes the patient to the dangers of con-
secutive hemorrhage, and of gangrene by default of circulation ; and is ex-
tremely slow of cicatrization.
By the method of Anel, on the contrary, we deal with tissues which are in
their normal state, and of which the relations have not been disturbed. It is
easy to exclude every thing but the arterial trunk from the loop of the ligature,
leaving untouched the nerves and veins, and all other tissues, the inclusion of
which mi^ht endanger more or less the success of the operation. The previous
compression of the vessel is not indispensable : the incision is clean, of slight
extent, and quickly and easily cicatrized. The operation is simple, easy of
execution, much less painful, and less protracted than the other method ; and
the artery not having been opened, and being tied at a point perfectly sound,
secondary hemorrhages are less to be feared, and much less frequent. As
the continuity of the tissues is not so much interrupted, the circulation
establishes itself more easily below the ligature .; the reaction in the general
system is naturally less powerful, and the gangrene of the member less to be
apprehended. But by the opening of the sac, the thread can be applied as low
as possible ; the tumor is immediately emptied ; a new disease is not added to
the original one 5 and all the collateral arteries which are given off above the
aneurism, are preserved. Tumors situated too near to the trunk to allow of
operation by the method of Anel, permit the tying of the two portions of the
artery at the aneurism. Again, if an arterial trunk has just been wounded,
and the place of the opening is known, it appears more rational in the first
instance to expose it at this place, than to endeavor, by inflicting a new^ wound,
to seek for it higher up. These, at least, are the reasons which have been
advanced, and which Mr. Guthrie still adduces in favor of the method of
Keisleyre. In order to repel these arguments, the partisans of Anel assert,
that after the lipture of an artery the circulation ceases, not only in the
point nearest to the bandage, but as far back as the first considerable collateral
branch given off in the direction of the heart ; so that in placing a ribbon on
the popliteal artery, the femoral itself is obliterated as far as the beginning
of the profunda, which shows that there is no advantage to be gained by dis-
covering this vessel in the inferior third of the thigh. Then, in regard to
tumors which are very near the origin of the limb, there is nothing at the
present day which can render the method of Anel inapplicable, when they are
susceptible of the operation of opening the sac. In diffused aneurism it can-
not be denied that the embarrassment produced by the effused blood, the
OPERATIVE SURGERY. 53
displacement and disorganization of the tissues, the difficulty of immediately
hitting upon the wounded part, and even of finding the vessel itself at the
bottom of a wound more or less irregular, and the depth to which this wound
must in some cases extend, present obstacles which certainly justify the prac-
tice of those who even then operate at a higher point upon the limb, especially
since any hemorrhage, which might return by the inferior portion of the artery,
could be easily arrested by compression properly applied.
Those who oppose the method of Anel, say, that in placing a ligature at some
distance from the seat of the disease, the blood and pulsations are likely to re-
appear in the cyst, and thus a grave operation will have been performed abso-
lutely to no purpose. Very often, it is true, the pulsations are revived in the
aneurism a short time after the application of the ligature, according to the
method of Anel ; the blood may return by anastomatic arches into the portion
of the arterial trunk comprised between the tumor and the ligature, and enter
into the aneurismal sac by its inferior opening, or perhaps arrive there directly
by some secondary branch; but experience has sufficiently demonstrated that
these pulsations very soon cease, or at least, that a moderate compression is
generally enough to put a stop to them. Reason, too, perfectly explains this
result. The blood which enters into the aneurism cannot do so under such
circumstances, without having traversed the capillary system, having passed
through very fine ramifications into the larger branches, and having conse-
quently lost a great portion of its ordinary impetus. Now, as it is sufficient
to determine the coagulation, that the blood should remain in a state of
oscillation or of stagnation, that it should cease to circulate in any point of
the vascular system, it is easily seen, that the disadvantage in question is far
from having the importance originally ascribed to it. \Vith regard to the
consecutive opening of the cyst, its suppuration, and inflammation, which have
been thought capable of endangering the success of the method of Anel, they
are circumstances generally too trifling to require attention, and which, even
when they prove otherwise, render the operation after all less serious than
that of Keisleyre; they are hardly ever seen except in cases where the
disease is much advanced, or the aneurism enormous and enclosed by very
slender parietes more or less disposed to mortification. The method of
Anel, then, possesses numerous and undeniable advantages over the ancient
method. Some persons, however, still persist in believing that this latter
should not be entirely rejected, and that it should be preferred, for example, in
cases of superficial diffused aneurism ; those which occupy the brachial artery
immediately in the vicinity of the armpit ; those of the axillary itself, when
the shoulder is infiltrated, or so much distorted that it would be dangerous to
attempt the operation, either before or above the clavicle ; in aneurism in
general, when it is very voluminous or threatens to gangrene, or is seated
near a large and important collateral branch ; and in varicose aneurism, which
imperiously demands, as we are assured, that the artery should be tied both
above and below its opening. This doctrine which is supported with great
zeal by Mr. Guthrie, appears to me to be very just, and altogether conformable
to the principles of sound surgery ; several facts, among which are the ligature
of the femoral artery, and a similar operation on the external iliac, which will
be mentioned in their proper place, have demonstrated to me the truth and
justness of this position.
The method of Brasdor, which is but a modification of Anel, possesses
consequently, as an operation, the same general advantages and disadvan-
tages. It is nothing more, however, than a make-shift, a last resort, applicable
only to cases which do not permit the employmeht of either of the others
54 NEW ELEMENTS OF
The cures obtained by this method, are explained in the following manner :
the blood circulates with less force in the aneurism than above and below,
according to a well-krfown law of hydraulics. With this predisposition, the
first effect of a ligature applied to the portion of an artery which brings the
blood to the aneurism, should be to arrest the circulation first in its cavity,
and afterwards, as far back as the supplementary branches by which tlie
blood can deviate from its usual course.
If the carotid, for example, should be tied near its bifurcation, it would be
obliterated step by step to its very origin ; that is to say, to the point where
it leaves the aorta or the subclavian. It is the same with the tibial, radial,
cubital, popliteal, brachial, and femoral arteries, respectively ; but if it is
sufficient to close an artery towards its capillary extremity in order to efface
the canal, it is evident that the aneurism, being situated between these two
points, would disappear almost as easily and as surely when the ligature was
used below, as if it had been carried above the seat of the disease. It may be
presumed, that according to the method of Brasdor, the pulsations would less
frequently reappear or be maintained in the cyst, than by the method of
Anel, unless one or more considerable collateral branches should be given
oft* between the ligature and the lesion. In this latter case, the operation
will without doubt have a less chance of success ; but still it appears to me
likely to very often succeed, provided the supplementary branches should be
two or three times less in calibre than the principal trunk, and do not allow
tlie blood a sufficient passage of deviation to prevent its stagnation in the
aneurismal sac ; and "provided the parietes of the latter should preserve suf-
ficient density to resist the efforts of the tumultuous throbbings, which it
generally lias to sustain immediately after the operation.
The value of the new method should not, however, be exaggerated. Of
fourteen subjects who have submitted to its application, eleven have died and
the twelfth has incurred the most imminent danger. A multitude of facts
scattered through the annals of the science, prove that the arteries are far
from being always obliterated to a great extent above the ligature. Warner
quotes a case of brachial aneurism which supervened upon amputation above
the elbow, and which it was necessary to treat by tying the vessel towards
the armpit. An amputation of the leg presented the same phenomenon to M.
Roche, in 1813, at Tarragona, and it was necessary to tie the posterior tibial
between the aneurism and the popliteal artery. Two instances of aneurisms
have been presented by Mr. Hodgson, which were closed at their inferior
origin, and which, nevertheless, burst or mortified. Mr. Guthrie says, that
several preparations in Hunter's collection, show a complete obliteration of
the artery beneath the bag, without a cure of the aneurism. In proceeding
to the ligature of the external iliac, according to the method of Brasdor, Mr*
White found the artery impermeable, and yet the aneurism continued to
increase, and I have at this time under my own observation, a woman who
undertook a month ago amputation at the knee, in whom the popliteal artery
has not yet ceased to beat strongly at the bottom of the wound ; and who has
not witnessed the same phenomenon in all similar amputations ? Now, if the
arterial cyst continues below the origin of the collateral branches, and at the
distance of one or two inches from the suppurating surface of an amputation,
or from the spontaneous obliteration of the vessel, it is difficult to see why it
must be otherwise after the formal application of the ligature.
OPERATIVE SURGERY. 55
Art. 7. — Manual.
Is it necessary, before practising the ligature of an artery, to subject the
patient to any preparatory treatment ? Is it necessary to wait for an advanced
period of the aneurism ? Or is it better to operate as soon as its existence is well
ascertained ? The preparatory compression recommended with the design
of favoring the development of the supplementary vessels, is wholly unneces-
sary. It has of late been generally abandoned, and it is not, in fact, proper
to employ it, except in cases where it offers some chances of being of itself a
means of cure. According to the old. method, there was no risk in delaying
the operation. The partial interruption of the course of the blood, produced
by the development of the tumor, would naturally render the collateral
circulation more and more free, and allow the hope of a certain number of
even spontaneous cures. Indeed, at the present time these feeble accessaries
are no longer esteemed, and the new processes are resorted to as early as
possible. Some persons have proceeded so far (but improperly, according to
ray opinion, particularly in important cases) as even to neglect all precautions
in regard to regimen or general therapeutics. One or two bleedings, if the
subject is of a robust or sanguine temperament, a diminution more or less con-
siderable in the quantity of aliments, bitter and diluting drinks, anodynes,
warm bathing, antispasmodics if there is agitation or great irritability, some
preparation of digitalis to diminish the force of the impulse of the heart, a mild
purgative when the digestive organs are clogged, and leeches if any local
mflamation is developed, will never be omitted by any one who knows how to
combine the principles of sound therapeutics with those of enlightened surgery.
§ 1. Old Method,
Apparatus. — According to the ancient method, the necessary apparatus was
composed of a convex, a straight, and a probe-pointed bistoury, a female sound,
some buttoned stylets, a spatula, needles of dilFerent forms, ligatures, a
tourniquet or a garot, agaric, lint, bandages, sponges, scissors, &c. The skin
whicii covers the aneurism and the parts about should be carefully shaved.
Position of the Patient and of ihe Assistants. — Thepatient being placed upon
a bed or table conveniently situated, an assistant is charged with the duty of
compressing the artery between the tumor and heart, witb his lingers, a rolled
bandage, theg-arof of Morel, the tourniquet of Petit, or some other instrument
of the kind ; a second assistant holds the sound limb, or faces the operator ;
a third presents or receives the instruments according as they are required
or become unnecessary ; a fourth and a fifth are sometimes of use in holding
the head or other parts of the body, from the movements of which any danger
might be apprehended.
Operation. — The passage of the artery being accurately known, the surgeon
proceeds to divide with the convex bistoury, first the skin and the adipose
stratum, and then at a second stroke the entire thickness of the cyst, beginning
a little above and finishing by about an inch below. After having removed
the coagula, and sponged and cleansed the botton of the wound, he then searches
for the opening of the vessel, relaxing for a moment the compression, if neces-
sary, in order more surely to arrive at it ; introduces by this opening a buttoned
stylet, the female or the grooved sound; raises the superior extremity of the
artery ; assures himself anew that it is really the artery which he has before
his eyes ; isolates it from the vein, the nerves, and the other tissues which he
designs to avoid ; passes the thread under it so as to embrace the sound at the
56 NEW ELEMENTS OF
same time ; seizes the two principal ends of this thread, which he draws towards
himself with one hand whilst he applies the fore-finger of the other upon the
raised trunk to feel the pulsations, to make himself sure that the artery has
been well taken up and that the ligature which has just been passed around
it will really efface its calibre; there is nothing more to be done then, but to
tie the ligature with a simple knot while an assistant withdraws the sound,
to fix this first knot by a second, and to cut one of the ends of the thread very
close to the artery. The inferior extremity of the vessel is subjected to the
same operation. The bottom of the wound is then filled with agaric, or better
with pellets of soft lint, which are covered with large pledgets smeared with
cerate ; over these are applied compresses, and all are confined by a simple
bandage which completes the dressing.
§ 2. Method of Anel.
When we operate without opening the sac, we may omit some precautions
which are necessary in operating by the old method. The position of the
patient, and of the assistants, is not materially different ; but the compression
of the artery above the tumor has no longer any particular object, and is
notliing more than a matter of prudence. The point upon which it is expe-
dient to apply the ligature, not being determined by the presence of the
aneurism, demands some further attention on the part of the surgeon.
Point of Election, — In spontaneous aneurisms the incision should be made
as far as possible from the tumor, because the nearer you approach it the more
reason is there to apprehend coming in contact with a diseased portion of the
vascular tunics. A contrary rule is to be observed in cases of traumatic
aneurism, because while you are sure in placing thethread very low of finding
the artery as healthy as any where else, you have the additional advantage of
leaving untouched collateral branches more or less important. If in any case
the operation should threaten to be much more difficult near the aneurism
(unless there should be a voluminous supplementary branch to sacrifice), you
would proceed to search for the vessel in that region where it would be more
easy and less dangerous to expose it. The farther from the cyst you operate
the less vou are likely to determine rupture, suppuration, or inflammation^
But we should not, in endeavoring to avoid one extreme fall into another;
that is, to carry the thread immediately beneath any great secondary arterial
branch. In fact the consequences of such an operation rarely fail to be trouble-
some ; not, as it has been too often repeated, because the coagula, of which
Jones has said so much, cannot be formed, but because the blood, finding a
free and very large passage immediately above the bandage, does not permit
the arterial parietes to approximate and form mutual adhesions. As it is
necessary to reach, by the nearest possible way, the artery which is to be tied»
the operator should first of all be perfectly acquainted with its course. This
knowledge is acquired by calling to mind the relations of the muscular
elevations, and of the furrows which separate them, as well as by the assist-
ance of the arbitrary lines invented by M. Richerand, which are drawn between
certain osseous projections.
Incision. — Whatever may be the decision on this point, the surgeon, placing
himself on the same side with the aneurism, begins the operation by stretching
the integuments, either transversely by means of the thumb, the fore-finger,
and the cubital border of the hand, or by applying the extremities of all
the fingers over the passage of the vessel in a line parallel to its direction, as
is advised by M. Lisfranc. The incision is then made through the skin to
OPERATIVE SURGERY. 57
the length of from two to four inches. This incision should be made with a
bistoury convex on the edge, rather than with a straight bistoury ; and it is
better to make it a little too long than too short. But in the greater number
of cases, whenever it is not necessary to penetrate deepljr, it is enough to
make an incision of two or three inches. Most commonly it is made in the
direction of the artery, but sometimes in that of the fleshy fibres ; in such a
case it may cross the vessel more or less obliquely. Care should be taken' to
avoid cutting too deeply at the first stroke : it is much better to repeat it a
second time in order to get through the skin, than to come unawares upon the
artery. After the integuments the aponeurosis is encountered, which is to
be divided in the same manner, if the artery still remains at some depth.
If not, or if the operator is not very sure of his hand, he passes a grooved
director under the artery, to serve as a guide to the bistoury. The other
lamellae should be successively divided, with the same precautions and to
the same extent. Having arrived at the lash of vascular and nervous cords,
the surgeon should first open the common sheath. The director is here
of the greatest importance. It is carefully entered either from the upper
towards the lower part of this sheath, or from the lower to the upper, taking
the precaution to raise it alone, and not to permit any of the parts which it
may be dangerous to wound to slide between it and the instrument. In order
then to isolate the artery, a grooved director is again used, which should be
of steel (rather than of silver or of gold), slightly flexible, somewhat conical,
without a cul-de-sac, and less obtuse than the ordinary probe. It is held in
the manner of a pen, and the extremity is inserted between the vein and the
artery. Then, by light movements to and fro, sustained, however, by a
pennanent though moderate pressure, the two vessels are separated to the
extent of several lines. In the same degree that this separation takes place
the operator reverses the position of the sound, in order that its beak (or nib),
inclined by degrees as it passes under the posterior surface of the vessel,
may present itself on the opposite side ; at this point the fore and middle
finger of the other hand remove the nervous trunks, or push backwards and
to the outer side all the parts which it may be designed to avoid. This same
director, before being withdrawn, should still perform another duty, that of
serving as a guide, as it is, to the passage of the ligature ; whether this is
effected with a simple silver probe with an eye at one end, such as is used by
M. Dupuytren, Richerand, and nearly all the French surgeons, or whether it
be thought preferable to use for deep ligature the curved needle held with the
pincers (described in the work of Dr. Dorsey), or the needle of J. L. Petit,
that of Deschamps, &c., Desault conceived the idea of using, where it was
necessary to operate at the bottom of a deep and narrow cavity, a spring-
needle very much like the probe of Bellocque, which has been modified m
England by Messrs. Ramsden, Earle, and Brenner. Sir A. Cooper in these
difficult cases uses a steel wire, supported by a handle curved at its free
extremity, and terminated by a knob, in the thickness of which is an opening
destined to receive the thread. Scarpa much extols a small spatula of pure
silver, very thin and flexible, which can adapt itself to the form of every part
which it may be required to embrace. But the grooved director, such as I
have already described, should rarely prove insufficient in the hands of a
skillful surgeon. It possesses above all the special instruments, and the
numerous needles which have been so carefully described by M. Holtz, in his
Treatise on Arterial Ligatures (published at Berlin in 1827), the inestimable
advantage of being able to isolate the artery with the greatest precision, and
almost without laceration of the adjacent tissues. When it has once arrived
8
58 NEW ELEMENTS OF
on the other side of the vessel, I cannot see how it should be- impossible to
slide the head of a flexible probe along its groove, and by this means to pass
the ligature. An eye might even be placed near its point, so that it might
pass the ligature at the same time that it separates and isolates the circum-
ference of the artery. For the rest, every practitioner may understand the
mechanism of these instruments, and can easily decide which should be
preferred to the others. It is not only useless, but even dangerous to
endeavor, as Scarpa advises, to raise and separate the vessel from the neigh-
boring parts, with the fingers. By this method the tissues are lacerated, and
a contused wound is formed, which must almost necessarily suppurate, while
it is of the greatest consequence that it should be as clean and as regular as
possible. Those who recommend to cut with the bistoury in a horizontal
position all the cellular lamellae which cover the artery, render themselves
liable, notwithstanding the most minute precautions, to wound it, or at least,
in the most successful cases, to prolong the operation.
The sound obviates these difficulties, permits the operator to act with more
safety and promptitude, allows him to place the ligature around the organ in
some sort, without displacing it or deranging its natural relations, and to
expose it to the slightest possible extent.
The ligature should be sufficiently tight to arrest completely the passage
of the blood, not only at the moment of the operation, but afterwards, which
cannot be done when it includes with the artery any muscular, tendinous, or
aponeurotic fibres, or even a shred of cellular tissue, because these parts of
course soften and relax the ligature, and soon render it almost inefficient. In
order to attain this end it is necessary to avoid passing the extremities of the
thread twice, one within the other, and forming what is generally called the
surgeon's knot. Under this knot, in spite of the most powerful constriction, the
centre of the circle sometimes remains open and permeable. This happened
to Chopart when, among the first in France, he attempted, in 1781, the ligature
of the popliteal artery. Several ligatures were successively applied without
being able entirely to suspend the circulation in the limb. Amputation was
performed before the patient was removed from the table, and upon examin-
ation of the parts it was discovered that not one of the ligatures had entirely
effaced the calibre of the vessel. Two simple knots are then to be preferred.
If the lij^ature is of an animal material, the two ends are cut off so as to
enclose the remainder in the wound ; if otherwise, one extremity is left to
hang outside. If, after having laid the artery bare, the operator perceives
that it is diseased, that the parietes are yellow, fragile, or encrusted with
calcareous plates, it might then be prudent to flatten it, as advised by Scarpa,
instead of tying as in other cases. Nevertheless, Messrs. A. Cooper,
Lawrence, and Briot have had no cause to repent having followed a different
practice, and ventured to place a simple ligature about arteries obliterated,
fragile, or entirely morbid. In such cases the strips used by Dr. Jameson
may be of great service, unless there be some chance of deriving advantage
from making a new incision, and practising the operation higher up.
Dressing. — The wound after being cleansed and freed from all foreign
bodies with which it may be connected, should be immediately closed.
Nothing is more to be feared than suppuration succeeding the ligature of
arteries. Immediate reunion, on the other hand, in almost every instance
ensures success 5 but it should be promoted from the bottom of the wound
towards the edges, and not from the skin in the direction of the deeper parts,
as the points of suture used by some surgeons tend to favor its occurrence.
Consequently the operator should confine himself to bringing the lips exactly
OPERATIVE SURGERY. 59
together, bj the aid of gradual compresses of strips of plaster, and of position.
Then, after wrapping a small piece of fine linen round the exterior portion
of thread, it is turned towards the most dependent angle of the incision, or to
that which is nearer to the knot, or it is brought directly out by the shortest
way between two strips of plaster. A compress smeared with cerate and
pierced with holes, is applied above, or sometimes small bats of lint are used
instead. With these precautions, there is then no hindrance after the first
dressing to the removal of the difi*erent parts of the apparatus. A pledget
of substantial lint, or one or two oblong or square compresses^ cover these
objects, and the dressing is terminated, according to the method of Kiesleyre,
by a few turns of the bandage to secure the whole.
Subsequent Treatment. — The patient being returned to his bed, is there
placed in such a ^tuation that all the muscles of the part upon which the
operation has been performed may be in a state of relaxation. The member,
supported by cushions, should, according to some, be surrounded by warm
aromatic bladders, or bags filled with ashes, sand, or bran, at the temperature of
about thirty degrees. By others it is merely surrounded with soft and pliant
pillows, suitably warmed ; some even neglect all special precaution, and make
no addition to the ordinary bed clothes unless the sensation of cold should
become very considerable. This latter practice is the one which is recom-
mended by reason. For either the circulation is re-established in the parts
where it has been for a time arrested by the operation, and the temperature
is of itself sufficiently elevated, or it is not re-established, in which case,
artificial warmth has no effect but to hasten the development of gangrene.
For the rest the operator proceeds as after all grave operations. Low diet,
repose, the most perfect quiet, demulcent drinks, acidulous, slightly
anodyne, or antispasmodic, are imperiously required. General blood-letting
may also become necessary, in order to prevent or to relieve congestion of
the viscera. It is most commonly useful to give the patient by spoonsful,
during the first twenty-four hours, a potion, into which enter some gently
aromatic liquid, some "of the tincture or extract of opium, and sometimes a
small quantity of ether or of Hoffman's cordial, in order to calm the state of
nervous irritation or agitation into which the patients are frequently thrown.
In such cases tepid linden-water is the most appropriate drink.
The first dressing should be made, at the soonest, on the third or fourth
day — the most exact precautions should be taken to avoid giving the least
motion to the member, exercising the slightest traction upon the ligatures, or
disturbing in the smallest degree, in raising the portions of the dressing, the
apposition of the lips of the wound, particularly when an immediate reunion
has been attempted.
The same care is necessary in all the subsequent dressings until the coming
away of the ligatures, which happens on the tenth, twentieth, or thirtieth day,
and which can be hastened by very gently pulling at the threads, if they are
slow in coming away, as soon as the obliteration of the artery appears to be
complete. When tne time of reaction is past, and the first symptoms have
subsided, when the limb has recovered its natural temperature and sensibility,
the severity of the regimen is gradually relaxed, and the patient is to be con-
sidered in this respect as convalescent. Yet, even after the complete cicatri-
zation of the wound, he should for a considerable time indulge only in gentle
and very limited movements, unless he would expose himself to death by
consecutive hemorrhage from the re-opening of the wound, as it happened ia
one case cited by Beclard.
60 NEW ELEMENTS OF
§ 3. Results of the Operation,
The operation for aneurism is sometimes followed by accidents or pheno-
mena which require particular attention.
1st. The limb, as we have said before, becomes more or less cold during
the first twenty-four hours. It then returns by degrees to its habitual tem-
perature ; sometimes, however, the coldness is succeeded by too much
neat, which produces an irritation high enough to occasion gangrene. Vacca,
and some other modern practitioners, have quoted examples of this descrip-
tion. The member should then be wrapped in flannel soaked in some
emollient liquid, or covered with cataplasms of the same nature. Perhaps it
would be as well to apply, according to the advice of M. Begin, leeches
to the points which are most painful and particularly threaten to become in-
flamed. Several reasons also lead me to believe, that in this case a rolled
bandage, moderately tight, would succeed more easily than any other means
in relieving this state. Cold water too would be a resource worthy of trial.
2d. Gangrene, which is too often a consequence of the ligature of
arteries, is not always preceded by this excess of heat. It more frequently
depends upon the circumstance that the circulation is not re-established.
The inferior part of the limb then remains cold and insensible, changes color,
becomes the seat of phlyctena, and soon develops all the other symptoms of
mortification. If the gangVene is not very extensive, or seems inclined to
limit itself, the surgeon proceeds in the same manner as when it is pro-
duced from any other cause — he waits until the sloughs are detached, and
the ulcers which result from them are cicatrized 5 but if it involve the whole
thickness of the limb, nothing but amputation can then save the life of the
patient.
3d. The sudden interruption of the course of the blood in a voluminous
artery, sometimes occasions such a derangement of the general circulation as
results in a high fever, signs of plethora and of congestion, or a great tendency
in some of the principal organs to become seriously inflamed. Under these
circumstances the antiphlogistic regimen should be enforced in all its rigor.
Recourse should be had to bleeding, whether general or local, and even repeated
as often as the strength of the patient or the acuteness of the disease may
seem to demand.
4th. In other cases, certain nervous symptoms present themselves, and become
troublesome. The pulse continues irregular, small, and quick ; delirium super-
venes ; convulsive movements take place, and most of the signs of the ataxic
fever are developed. Antispasmodics generally, but opiates, above all, are
the remedies which are recognized as best in cases of this description. It
would appear, that in a case treated by M. Gama, at Val-de-Grace, he found
himself forced to administer laudanum in very large doses, in order to relieve
this state, and that the delirium with which patients are attacked, bears some
analogy to the •' delirium tremens^^ to which drunkards are frequently
subject.
5th. Ordinarily the tumor subsides or at least is diminished, and ceases to
beat, immediately after the application of the ligature. At a later period it
becomes hard, and contracts; the blood which it contains becomes concrete
and is gradually absorbed ; and the whole tumor, after a certain length of time,
finally disappears, or only forms a small tumor, a mere kernel, hard, movable,
and free from pain. Instead of these phenomena, others sometimes super-
OPERATIVE SURGERY. 61
vene. The pulsations which had ceased for a time, reappear at the end of
several hours, or of several days ; the tumor resumes its original size, and the
operation appears to 'have had no influence whatever upon the disease. This
takes place sometimes because the superior collateral branches open either
directly into the tumor or between the tumor and the ligature, and thus in-
troduce the blood in too great abundance ; and sometimes because the fluid
returns into the cyst through the inferior part of the artery. For the rest it
is an accident less important than it was at first considered. Observation has
demonstrated, that in a majority of cases the system will finally prevail.
Whenever topical refrigerants, with the due application of the rolled bandage,
or any kind of compression continued for some weeks, produce no advan-
tageous change, it is necessary then to see whether it would not be more safe,
if possible, to apply a new ligature close to the tumor, either above or below,
or else to operate according to the ancient method.
6th. Instead of subsiding, hardening, or finally resolving itself, the aneu-
rismal sac sometimes becomes hot and even inflamed, and tends to form an
abscess. If cold topical applications, astringents, or compression, do not pro-
duce the effect we desire from them, then leeches and emollient cataplasms
should be promptly substituted. But if suppuration should occur, manifested
by decided fluctuation, it would be necessary to treat the aneurism as a simple
abscess, to open it largely with the bistoury without too much delay, to
empty.it of the detritus which it contains, and to dress it then like any other
suppurating wound.
7th. Immediate reunion is not always effected^ although every thing may have
been done to attain that end. Pus sometimes stagnates at the bottom of tlie
wound, extends itself widely, and separates the tissues; and the muscular
sheath, and that of the artery, becoming inflamed, soon suppurate in their turn.
The patient is then in the greatest danger. The surgeon is then obliged, in
order to resist these troublesome symptoms as soon as they are perceived, to
divide freely the skin and all the layers wiiich hinder the free issue of pus or
other effused fluid, to lay open the wound to the bottom and through its whole
extent, and to give up entirely the hope of effecting reunion by the first
intention. When, in spite of all his efforts the surgeon perceives that sup-
puration is fairly established and spreading, and continuing long enough to
enfeeble the whole organic system, or to give rise to fears of adynamia or of
exhaustion, he must then endeavor to retard its progress by general remedies,
to sustain the strength of the patient, to administer the extract, syrup, de-
coction, or other preparation of Kina, a little good wine, li^ht but substantial
aliments, &c., and occupy himself at the same time in modifying the ulcer by
topical agents or appropriate incisions.
8th. 'llie accident which has most occupied the attention of practitioners
as a consequence of ligature of arteries, is that of "hemorrhage," though
happily the degree of improvement to which the operative methods have
arrived, renders it at present but of rare occurrence. It is most frequently
observed, when in operating on a trunk in the vicinity of the heart, it has
proved impossible to avoid placing the ligature very near a great collateral
artery ; when the tape has been badly applied, when it is displaced, when it
has not been drawn sufficiently tight,"when it has been fixed upon a diseased
part of the vessel, or when this by any cause whatever is morbidly affected
either above, or even in certain cases below the ligature. The hemorrhage
again may be ascribed to the rupture of the sac, and may manifest itself m
the first few days, or may delay its appearance for a long time after the
operation ; may depend upon the state of irritation in the wound, and may, in
62 NEW ELEMENTS OF
some cases, be nothing more than a simple exhalation. The compression of
the artery on the side towards the heart, compresses, lint steeped in cold
water, or impregnated with the powder of Bonafoux, or with the liquid of
Binclly,Talrrich, or Halmagrand,or with any other hemostatic substance, and
applied to the part from whence the blood appears to emanate, are the first
means to be put in use. When these are not sufficient for the purpose, you
are then compelled to remove the dressings and all the effused blood, to
tampon the sac, and have recourse to mediate compression. If these last means
should prove insufficient, nothing is to be done but to choose whether to search
for the two extremities of the artery at the bottom of the wound, and to tie
them anew, or to apply the ligature at a higher point upon the limb. But
happily we can more irequently dispense with this resort, and suppress the
hemorrhage without a renewal of the operation.
Art, 8.— Of the Suture,
About tlie middle of last century, Lambert, an English surgeon, thought he
could cure wounds in the arteries by means of a twisted suture. Observing
that after bleeding, veterinary surgeons generally close the vein, with a needle,
he conceived the idea that this method, being applied to the arteries of the
human subject, would be productive of the same results; several experiments
confirmed him in this opinion, and his efforts in this were crowned with com-
plete success in the case of a patient affected with a traumatic aneurism in
the arm, whom he caused to be examined by the members of a medical society
in London. Suture, it must be observed, appeared important in the eyes of
Lambert, because he thought it would permit the conservation of the calibre
of the artery ; but Asmann having proved that he was mistaken on this point,
and that the suture never succeeded but by obliterating the vessel, his propo-
sition was soon forgotten, and has never since been revived.
Art. 9. — Torsion, Bruising*
Torsion, which is sufficient to arrest the progress of traumatic hemorrhage
whenever the open extremity of the vessel can be isolated and conveniently
seized, appears, from the experiments of M. Thierry, to be also capable of
curing aneurisms. After having publicly advanced this idea at a concours,
where he contended for the place of surgeon to the central bureau of hospitals,
in the spring of 1829, M. Thierry made a certain number of experiments on
the carotid arteries of horses. This process consisted in raising the artery
with the needle of Deschamps, which he then made use of as a garot, in order
to twist it always in the same direction a number of turns in proportion to
its size or calibre: that is to say, four turns for a small artery, six, for one
of middle size, and eight or ten l"or the more voluminous trunks. This prac-
tice has always effected the complete obliteration of the vascular canal, so as
to permit immediate reunion, and to leave no foreign body remaining at the
bottom of the wound ; I do not think, however, that tnis new method should be
generally adopted. In order to carry it into execution, it requires that the
artery should be isolated to a considerable extent, and the reduction of length
which it must undergo cannot but endanger the success of the operation. It
would appear almost impossible to avoid stretching the veins, nerves, and other
adjacent parts, even if we proceed in the manner of Mr. Lieber, who has
equally interested himself in this subject. And afterwards, it is by no means
OPERATIVE SUkGERY. 6S
certain that the twisted organ does not present, in case of mortification, a
foreign body more injurious than a simple ligature.
Others have thought that, after exposing the artery it would suffice to seize
it with two pincers with flat blades, to twist it laterally so as to bruise the
internal and middle coats, to crowd up the broken coats acting through the
cellular coat, and to close the wound immediately in order to arrive at the
same result. M. Carron du Villards says, that he made several experiments
on this point with M. Maunoir, and that they were generally successful.
These experiments were suggested to me in 1 820, says he, by Professor Mau-
noir, sen., who at that time spoke to me of an instrument for breaking the
internal tunic of the arteries without having recourse to the ligature. This in-
strument consists of a forceps similar to those of M. Amussat, for the torsion of
the vessels, but has no teeth, and its free extremity is formed by two little
ridges like grains of barley, which meeting, when closed, crush the artery and
break the inner coats without affecting the outer. With the instrument of
Maunoir, the closure of the arterial canal is almost always secured : but care
should be taken to bruise it in several places ; for if, as recommended by
Jones, it is broken in only a single point, the effusion of the plastic lymph,
which is designed to dam the current of the blood, is not sure to be determined.
And we see that when a large artery is to be acted upon, if we breathe only
one-third of its canal, or apply only two strokes of the pincers, as if to remove
a lozenge of its tube, an aneurismal tumor is almost always in a short time
the result. I had the honor to exhibit a tumor thus produced, to M. Pacoud,
surgeon in chief of the Hotel Dieu, at Bourg who had favored me with the
privilege of the amphitheatre of that hospital for the prosecution of a series of
experiments upon animals.
The attempts of M. Carron have been since repeated by M. Amussat with
full success ; but with this surgeon the rolling up of the broken tunics is the
principal point of the operation, and this is the characteristic of his process.
It is to be feared that we maybe deceived in signalising this latter modification
as a benefit. The membranes thus turned Up, will no doubt sometimes close
the artery ; but besides the fact that such an event does not always take place,
I see the disadvantage of being obliged to expose the vessel to a great extent,
to isolate it from the vein and the nerves completely around, and that to a
great length, the same as in the process of M. Thierry — circumstances calcu-
lated to prevent immediate reunion, and to render the operation more tedious,
more painful, and less sure, than the application of the actual ligature.
Acupuncture.
Some years since, whilst 1 was endeavoring on a certain occasion to separate
the femoral artery of a dog from its corresponding vein, and was just pushing it
to one side with a pin, some person entered and obliged me at the moment to
suspend my operation. A motion of the animal caused the pin to sink through
the artery, and it was lost in the thickness of the limb. It remained there
until the fifth day. On careful examination of the parts, I was fully con-
vinced that the obliteration of the vessel had been the consequence of this
puncture. Such an effect struck me with some surprise, and appeared at first
quite extraordinary. But I soon succeeded in explaining it in a satisfactory
manner. If it is actually true that it is sufficient to retain the ligature for an
hour or two on large arteries, in order to produce the obliteration, as we are
told by Jones, Hutchinson, Travers, and others, it should then be possible to
64 NEW ELEMENTS OF
attain the same end by occasioning, on a given point of these canals, any morbid
Srocess whatever, which shall be capjible of interrupting the course of the
aids, and thus producing coagulation. Impressed with the idea that the
contractions of the heart have less influence on the motion of the blood than
has been generally imagined, I soon conceived how a foreign body, howeVer
small, kept across the vascular canal, or causing any elevation upon its interior
surface, should be capable of producing the same effect as the ligature. So
if an osseous or calcareous lamella, free at one of its edges, and adherent at
the other, turns itself and juts into the artery where it was first developed,
there is every reason to believe that it may become the centre, the nucleus,
or the cause of a fibrinous concretion, capable of deadening, in a greater or less
degree, the impulse of the blood, and of finally occasioning the obliteration
of the vessel. The observations published by Mr. Turner, those which have
been communicated to me by Mr. Carswell, and some others of my own, put
this fact beyond doubt. What I have advanced in regard to an osseous spicu-
lum, is evidently applicable to every species of prominences, asperities, or in-
equalities, which in any way diminish the normal regularity of the conduit
through which the blood should circulate.
I am aware that this reasoning is liable to attack on more sides than one ;
80 I give it for what it is worth, without attaching to it too much importance.
But I resolved to submit it to some trials, in order to see if it would be
possible for me to produce the same results, at will, which I had at first obtained
by chance.
In the month of June of last year, I made some experiments with this view.
An acupuncture needle, an inch and a half in length, was passed through the
artery in the thigh of a dog, without previous dissection ; I then placed two
others on the opposite side, in order to see what difference of effect might be
the result. In examining the parts on the fourth day, I found my first needle
on the external third of the femoral artery, which was only one half closed ;
of the last two, one was found immediately outside of the vessel, which was
obliterated by a solid clot of blood, about an inch in length, in the middle of
which the second needle was discovered firmly fixed.
I renewed these experiments in the month of November following : thenin
the month of February, 1830. They were again repeated in April last, by
M. Nivert, then the preparator of my course of operations, and now doctor of
medicine at Azai le Rideau. I have more recently subjected them to other
proofs at the hospital of La Pitie, and always with the same effect. In order
to be more certain of not following upon the side of the artery, I have always,
in these latter experiments, taken tlie precaution to expose it ; sometimes I
have only used a single needle, at others I have operated with two, and even
three, according to the size of the vessel. Whenever a foreign body had
been able to retain its place for at least four days, a small clot of blood has
formed itself in the punctured part, and the obliteration of the vascular canal
has resulted. The aorta under tnis treatment, however, experienced no change 5
but as the needles had only remained in position for a little more than twenty
hours, I do not think it just to draw any positive conclusion from this cir-
cumstance.
It is proper besides to say, that up to the present time my experiments have
been made upon dogs of inferior size, and that the femoral is the most volu-
minous artery I have yet pierced. It is sufficient to say that before drawing
any practical inferences from these experiments, or applying them to the human
subject, they should be repeated and varied upon animals of a larger size
OPERATIVE SURGERY. 65
than the dog. I should even add, that according to the observation of M.
Gonzales, my experiments, upon being repeated by M. Amussat, have not
produced results equally conclusive.
A single pin or needle has appeared to me sufficient for arteries which do
not exceed in size the barrel of a quill ; two or three for those one-half larger,
and there would be no objection to the employment of four, or even of five,
for the greater arteries. When many are brought into operation, it is
necessary to place them at from four to six lines apart, in zig-zag position
rather than in straight line.
If similar results could be hoped for on the human subject, the immense
advantages which would be gained are obvious at a glance. Thus, instead
of the hazard of wounding the nerves or the veins ; instead of the dissection
so minute, and often so dangerous, which is required for the ligature, torsion
or bruising, it is sufficient to expose one of the faces of the tube to the
slightest possible extent, without removing any part, in order to secure its
obliteration. Perhaps even the most alarming aneurisms may be cured by
this means, those of the thigh and of the popliteal space, among others, without
dividing the skin ; that is to say, by merely piercing the femoral artery in
the bend of the groin with an ordinary pin, an acupuncture needle, any
metallic wire whatever, or even piercing the aneurismal sac itself in difterent
directions, with these foreign bodies ; but I very much fear that it will fare
with puncture as with seton, torsion, suture, and bruising ; and that ligature
will long continue to be preferred to these different means, notwithstanding
the species of infatuation with which many practitioners, otherwise much to
be commended, have been seized on this subject.
Art. 10. — Changes occurring in the vessels of a limb after the operation for
Aneurism.
When an artery ceases to be permeable to the blood, after having been
strangled with a ligature, alterations occur about the wound which are
worthy particular attention. Among these alterations some are generally
admitted, but the existence of others is not fully ascertained, or at least is
still under discussion. The blood, obliged to take another route in order to
arrive at the inferior part of the limb, crowds into the collateral branches,
dilates them by degrees, speedily gives birth to anastomatic arches of such
dimensions, that branches, before hardly visible, now acquire the size of a
crow's-quill, and that other branches, somewhat larger, at last equal the
third part or even the half of the principal trunk. The ease with which
these supplementary courses are formed or developed, gives to the operation
• for aneurism such prompt and complete success, and causes the throbbings
of the pulse which have been for a moment suspended, to reappear
below the ligature. But if all are of the same opinion on this point,
it is otherwise with the question whether new arteries are developed
in order to re-establish the course of the blood after the interruption of
the diseased trunk. Dr. Parry has been one of the first to speak of the
regeneration of the vessels, which he admits as an incontestable fact. —
He has seen, he says, the two ends of the carotid communicate with one
another by many small vascular branches, a long time after having been tied
or divided. It was with difficulty that he was at first believed, and his
assertions did not command the attention to which he thought them entitled.
At the same time or shortly after, according to' the evidence of M. Foerster,
a military surgeon, Mr. Ebel, arrived at nearly the same results, by experi-
9
66 NEW ELEMENTS OF
ments repeated upon more than thirty animals. M. Sallemi, of Palermo, M.
Zuber, of Vienna, and M. Seller, have not been less successful. More
recently M. Schcensberg has renewed the experiments of the English
physician on the carotid arteries of goats and bucks. He affirms that he has
found upon these animals new branches of considerable volume, forming a
net-work extremely complicated between the two ends of the divided tube.
If the drawing presented byM. Foerster represents exactly what the surgeon
of Copenhagen professes to have established, nothing can be more admirable
than the efforts of the organization under such circumstances. It appears to
me, however, that the operator sometimes deceives himself on the importance
of this reproduction of the vessels, and that it is admitted oftener than it
really occurs. To the facts reported by M. Schcensberg, even allowing them
full credit, may be opposed innumerable observations gathered from the
human frame. If the new arteries reunited the two ends of that which
had been divided, they would have been found upon the bodies of subjects
who had died sooner or later after the operation for aneurism. Now, the
finest injections, the most attentive and delicate dissections, have never been
able to point out their existence. Instead of this complicated net-work,
which has been spoken of by the authors Avhom I have quoted, there is
nothing to be found but a flexible cellular cord, impermeable to fluids, which
is insensibly confounded with the adjacent cellular tissue, and there are no
new arterioles to re-establish the continuity of the intercepted trunk.
If I am not mistaken, the assertions of MM. Parry, Bell, Mayer, Foerster,
Seiler, Zuber, and Schcensberg, are founded upon a phenomenon not yet
sufficiently observed, but which might perhaps explain the results at which
these authors think they have arrived. The albuminous effusion which is
created, and which concretes around the ligature in order to form the ring
spoken of by M. Pecot, may become the seat (when it is fairly organized)
of a vascular net-work of new formation, a thing often remarked in conformity
with a general law in a great variety of accidental organic productions ; these
small vessels which present at first the appearance of tortuous capillaries, of
simple hollow canals in the midst of an irregular substance, and in which the
fluids and the blood circulate rather under the influence of chemical or physical
laws than by the impulsion of the heart, continue as long as the virole remains
isolated, and has not yet become a part of the surrounding tissues ; but as this
organic mass, abating little by little, gradually assumes the character and
appearances of cellular tissue, properly so called, these small canals contract
themselves in the same proportion, and finish in their turn by differing in no
respect from the capillaries which run through the general lamellar system ;
whence it follows, that being susceptible of distention by matters of injection,
thej^ may have been observed, and even have presented a considerable volume
during the first and second week after the operation, whilst at a more advanced
period it would have been no longer possible to find them. They have then
no part in the re-establishment of the circulation in the limb. A phenomenon
of a similar description, but much more important, occurs at the spot where
the capillary ramifications of the superior collaterals communicate with the
capillaries of the inferior branches of the obliterated artery. According to
the experience of MM. Kaltenbrunner, Wedmeyer, Dcelinger, Blainville, and
others, the arteries discharge the blood with which they are filled into the
irregular or parenchymatous cellular tissue, before it is taken up by the other
vessels. In this organic course the fluids ooze rather than circulate. They
act, so to speak, after the manner of water which escapes from a river,
spreading itself by a thousand little channels through a plain of sand ; at each
OPERATIVE SURGERY. 67
moment new conduits are cut, whilst the former ones disappear. The blood,
no longer able to pass by its primitive central canal, creates for itself a number
of passages, which organize themselves afterwards by degrees, in order to
transfer it from the superior part into the inferior of the closed vessel ; and
it is without doubt to this effort that we must attribute the heat, the sensibility,
and the redness, which are sometimes manifested under the skin, at the expi-
ration of one, two, or three days after the operation for aneurism.
CHAPTER II.
* OPERATIONS FOR THE PARTICULAR ANEURISMS.
SECTION I.
Operations for Diseases of the Arteries of the Inferior Extremity.
Exposed more than in any other part to external agents, being very
numerous and for the most part large, the arteries of the inferior limbs are
naturally subject, and more so than any others, to all the diseases of the
arterial system. The surgeon is then frequently called to practise upon them
very serious operations. But the main trunks, and their principal branches,
are the only ones upon which these operations can be executed with advantage;
so that we need only speak under this head of anterior and posterior tibial,
peroneal, popliteal, femoral, circumflex, and iliac arteries.
Jt. Anterior Tibial in the Foot.
Art. 1. — Anatomical Remarks.
The anterior tibial emerges upon the foot from under the annular ligament
of the tarsus, a little nearer to the internal than to the external malleolus ;
from thence it is carried obliquely inwards towards the first interosseal space
of the metatarsus, which it penetrates from above downwards, to reach the
sole of the foot, and forms there the plantar arch by anastomosis, with the
external branch of the posterior tibial. It is separated from the bones and
their ligaments by a simple layer of adipose cellular substance, and accom-
panied, sometimes on the inside and sometimes on the outside, by the internal
branch of the deep dorsal nerve of the foot, and on the opposite side by its
satellite vein. It is covered, proceeding from the deeper parts towards the
skin : 1st, by a fine fibrous or fibro-cellular lamellae, which separates it from
the surrounding tendons; 2d, by a cellulo-adipose stratum, which is not
always present ; 3d, by the dorsal aponeurosis of the foot, which must be care-
fully preserved from being confounded with the subcutaneous stratum ; 4th,
by this subcutaneous lamellae, which is thicker and fatter upon children,
women, and others who are somewhat embonpoint, than upon men, or upon
persons of a meagre habit, in which layer lie the superficial dorsal nerves and
veins ; 5th, lastly, by the skin the thickness of which is also very variable.
68 NEW ELEMENTS OF
The first tendon of the common extensor of the toes is on the external side,
that of the extensor of the great toe on the internal. The first fasciculus of
the extensor brevis muscle crosses very obliquely from the outer to the inner
side, and from behind forwards the anterior half of its length. Its tarsal
and metatarsal branches are of too little importance to be described here,
but it is not so with its anomalies. I have once met with it immediately under
the skin, but more frequently it is wanting. A branch of the peroneal some-
times takes its place, at other times it is replaced by a strong branch of
the posterior tibial. It is true that these varieties are calculated to embarrass
many young surgeons who are practising upon the dead subject, but I do not
see that this embarrassment can occur during life. In fact, if Die vessel does
not exist, there is no lesion which can render the search necesstuy. If it is
given off by the posterior arteries of the leg, its dilatation towards one of the
borders of the foot will not admit the idea of seizing it in its customary place,
Supposing that there is occasion to operate upon it in consequence of a wound.
Art. 2. — Surgical Remarks, ^
M. Boyer asks, if aneurism of this artery in the foot has ever been
observed. Pelletan, Scarpa, Richerand, and Dupuytren, also, appear never
to have observed it ; whence we may conclude that it is at least of rare
occurrence. Guattani mentions having seen an example occasioned bv the
operation of blood-letting; and M. Roux also mentions two cases where the
division of this artery was tlie cause of troublesome hemorrhage. M. Vidal
has published in the Clinique, a similar observation made in the hospital
Beaujon. It is evident that should such a thing occur, compression would
frequently be sufficient ; and that in operating according to the modern method,
the artery should be tied in the leg and not in the foot ; but as it may become
necessary to obliterate the vessel before and behind the affected part in con-
sequence of the presence of the plantar-arch, to operate, in short, according
to the ancient method, the surgeon should know how to expose the anterior
tibial in the foot.
Art. 3. — Manual.
The patient should be laid upon his back, with the leg slightly flexed and
the foot moderately extended. An assistant takes hold of the limb, clasping
it above the ancles. The surgeon, with a straight or convex bistoury, makes
an incision through the skin of about two inches, in the direction of the oblique
line which runs from the middle of the instep to the first interosseous space;
divides the subcutaneous stratum, endeavoring to avoid the principal venous
and nervous branches which it contains; arrives successively at the aponeurosis,
at the space between the tendons of the first two toes, at the second fibrous
stratum, and finally at the artery itself, which he separates from the veins,
the nerve, and the cellular tissue, by means of the channeled sound. He
tlien passes the thread and ties it, after being well assured that he has taken
up nothing but the artery. Two diachylum straps bring together the lips of
the wound, and the operation is finished.
OPERATIVE SURGERY. 69
B. Anterior Tibial in the Leg.
Art. 1. — Anatomical Remarks.
Tlie anterior tibial artery arises from the popliteal, and after having pene-
trated nearly at right angles the superior part of the interosseous ligament,
descends in the direction of an oblique line drawn from the middle of the
space between the head of the fibula and the spine of tlie tibia, tov/ards the
middle of tiic instep, or to the point at which it passes under the annular
ligament. As it is applied almost immediately upon the interosseous ligament
in the upper two-thirds of its length, and afterwards on the external face and
front of the tibia, it is naturally situated at a depth proportionate to the
elevation of the point at which it is sought. The two veins which attend it,
often communicate with one another in front of it by means of small transverse
branches. The nerve of the same name crosses very obliquely its anterior
face, in a direction downwards and inwards; sometimes, however, it remains
outside as far as the instep. A pliant and not very abundant cellular tissue
surrounds these different organs, and unites them without furnishing them a
real sheath. The anterior tibial lies between the common extensor muscle
and the anterior tibial above ; between the anterior tibial and the extensor of
the great toe ; in the middle and between the extensor of the great toe and the
common extensor in the lower part of its course, and seldom presents ano-
malies worthy of the attention of the surgeon. Neither are the branches which
arise from it, with the exception of its recurrent branch, of any importance in
actual practice.
I have seen it twice becoming superficial from the middle of the leg. In
one of these cases it proceeded, as is usual, from the popliteal ; in the other,
instead of crossing the interosseous ligament, it turned the outside of the fibula,
and followed the track of the musculo-cutaneous nerve. It is no doubt to
one of these two variations that we should attribute the pulsations observed
by Pelletan in the front of the leg of a patient, and which was near deceiving
this able practitioner into the belief that an aneurism existed in the part.
Fortunately it is enough simply to call to mind the possibility of such an
anomaly, in order to comprehend, as well as to avoid the errors which it might
occasion.
Art. 2. — Surgical Remarks,
Since it is sustained by the interosseous ligament behind the bones of the
leg on tlie sides, and by muscles which are forcibly bound down in front by
a firm aponeurosis, the anterior tibial artery should rarely become the seat of
spontaneous aneurism. For my own part, I do not know of a single instance,
unless the sanguineous tumor mentioned by Pelletan, which destroyed by
erosion a large part of the superior extremity of the tibia, may be regarded as
such. Traumatic aneurisms of this artery are, on the contrary, frequently
remarked. They are sometimes circumscribed, but more frequently diffused.
and are produced by puncturing or cutting instruments, by balls and all
descriptions of projectiles, by osseous spicula in fractures, &c. J. L. Petit,
Desault, Deschamps, Dupuytren, Pelletan, Boyer, Roux, and Cowan, cite
observations of this disease, and prove that it may occur at any point in the
length of the limb. .
In a case of consecutive false aneurism of which he has spoken, Deschamps
operated according to the old method. Mr. Guthrie exclusively adopts the
70 NEW ELEMENTS OF
same in such cases, and strongly opposes those who operate in a diiferent
manner. If the blood continued to flow from the wound, if the accident was
but of recent existence, if the opening of tlie artery appeared to be easily dis-
covered, one might or even ought to follow the practice of these two authors 5
but in every other case the method of Anel is much to be preferred. It does
not appear to me by any means necessary to place a second ligature beneath
the tumor or wound, as some surgeons have advised, as a moderate pressure
will fully supply its place. If, however, the disease should be seated in the
superior third of the leg, it would be difficult to tie the artery above without
toucliing the tumor, and of course to operate by any other than the old method.
In that, and in everv other case where there is much difficulty apprehended
in operating on the feg, there still remains, as a final resource, the ligature of
the popliteal or the femoral. M. Dupuytren was the first to use it successfully.
In 1810, in operating upon a woman of sixty years of age, who had been
brought to the Hotel Dieu, affected with a large diffused aneurism resulting
from a compound fracture of the leg. M. Roux has derived the same advan-
tage in a case of hemorrhage following amputation below the knee, and M.
Delpech has obtained several similar successes. Mr. Guthrie, however, who
professes to have seen this operation practised at the battle of Albufera, and
of Salamanca, before our compatriots had even thought of it, strongly objects
to this practice. In the case of a soldier operated upon in May, 1814, hemor-
rhage returned by the wound, amputation became necessary, and the patient
died. The same thing occurred with a soldier wounded at Salamanca. Accord-
ing to his opinion, it is much better to open the tissues freely at the risk of
dividing the muscles, but it appears to me that the English surgeon goes too
far, although without being entirely wrong. Even allowmg it true, as a general
rule, tliatthe operation may be more sure, according to Mr. Guthrie's sugges-
tion, yet the practice of M. Somme, of Antwerp, lias sufficiently proved that
tlie advice of M. Dupuytren may be followed with advantage.
Art. 3. — Manual
The patient being placed in the same position as in the operation on the
lower part of the artery, should have the leg held with the toes somewhat
turned inwards, and disposed in such a manner that the muscles of its ante-
rior region may be extended or relaxed at will, by the assistant acting upon
the foot. In order to reach the artery in the inferior third of the leg, an
incision must be made through the skin, the subcutaneous stratum, and the
aponeurosis, to the extent of about two inches on the above described lines ;
then, with the fore-finger or with the extremity of a grooved sound, the tendon
of the extensor muscle of the great toe is separated from that of the anterior
tibial muscle, by pushing it outwards, if the operation is performed high up,
and on the contrary by forcing it inwards if quite low down. This being
done, notliing remains but to isolate the artery from its venas comites and its
accompanying nerve in order to tie it, to bring together the lips of the wound,
and to apply the appropriate bandage.
In its middle part, or in its two superior thirds, this artery can be exposed
by several different means.
1st. Process of M, Lisfranc. — In the process attributed to M. liisfranc,
by Messrs. Coster and Taxil, the incision in the skin is made obliquely from
below upwards, from the crest of the tibia toward the fibula, one or two inches
from the horizontal line. After the aponeurosis has been cut across, the
interstice which separates the anterior tibial from the extensors is sought for.
OPERATIVE SURGERY. 71
and as it is the first which is encountered on the outside of the tibia, it is
easily discovered.
2d. Ordinary Process. — In the common process, the incision is made parallel
with the direction and over the course of the artery, always taking as a guide
the above-mentioned line, or the middle of the space which separates the
fibula from the crest of the tibia, or the slight depression which naturally
corresponds with the interval between the muscles to be separated ; or lastly,
the operator may simply carry the bistoury an inch to the outside of the ante-
rior edge of the ie^. The aponeurosis, as well as the skin, should be divided
to the extent of three or four inches ; a yellowish line points out the muscular
interstice, upon which the fore-finger is placed to separate the muscles, and
to descend perpendicularly upon the interosseous ligament. At the bottom
of this interstice is found the vessel, which the operator endeavors to isolate
or to take up. This, however, is the most difficult stage of the operation.
After having caused an assistant to flex the foot, and properly to separate
the muscles, the best means of managing the artery, in my opinion, is to slide
the grooved sound beneath it very obliquely downwards and towards the
tibia, instead of carrying it transversely or from the anterior ridge towards
the exterior border or the leg. In order to estimate the utility of this direc-
tion, it is sufficient to call to mind that the fibula is almost on the same plane,
whilst the crest of the tibia is considerably above the level of the vessels. The
needle of Deschamps might nevertheless be easily used, as well as any other
kind of port ligature.
No one at the present day will be tempted to follow the example of Dr.
Hey, in cutting out a portion of the fibula, to arrive more easily at the tibial
artery ; as this sur;^eon affirms that he has once done with success.
M. Lisfranc thinks that the oblique, rather than the parallel incision, dis-
plays more clearly the interstice which is to be our guide, and also the
vascular tube itself. This decision is correct on the first point, but if I may
believe the result of frequent experiments on the dead subject, it is not alto-
gether the same upon the second. So that without entirely rejecting his
method of operating, I am still induced to prefer that of the other surgeons,
at leasj/ in ordinal y cases, and in every instance where there are no special
indications to fulfill.
a Posterior Tibial.
Art. 1. — Anatomical Remarks.
The posterior tibial artery from its beginning, a little below the popliteus
muscle, down to its division into the internal and external plantar arteries,
follows exactly the direction of a line somewhat convex inwards, and extending
from the middle of the beginning of the calf to a point half an inch behind the
internal malleolus. It is generally accompanied by two veins of considerable
size, which even sometimes form an actual net-work around it by frequent
anastamoses. On its fibular side lies the posterior tibial nerve, which is
rarely more than three of four lines from it. Resting in its whole extent
upon the deep seated muscles, it is covered by the aponeurosis which lies
between the two fleshy strata of this region, by muscles or cellular tissue,
and some more fibrous lam ellse, then by the common integuments. But there
are differences at some points in its length which it is important to note.
1st. In the Calcanear Arch. — The posterior tibial artery is applied against
the fibrous sheath of the common extensor of the toes, at about three lines
72 NEW ELEMENTS OF
from the posterior border of the malleolus ; the nerve is behind, and the
veins on the inside; a lamellous or adipose tissue envelopes it ', the internal
ligament of the tarsus, a species of fibrous lamina, continuous with the apo-
neurosis of the leg, covers and confines it, and confounds itself with tlie dense
and filamentous tissue which separates the vessel from the skin.
2d. Between the malleolus and the calf it has receded somewhat from the
internal edge of the tibia. The nerve lies rather on the outside than behind.
The lamellae which immediately surround it, are very pliant, and frequently
loaded with fat. The deep-seated aponeurosis, which is here quite thin,
keeps the vessel applied against the posterior tibial muscle, the long common
flexor, and the long flexor of the great toe. On the outside of this layer is
found the tissue which fills the sheath of the tendo Achilles, and then just
within the skin, the common aponeurosis of the leg.
3d. In the calf of the leg the tibal artery is deeply seated, almost upon
the same plane with the posterior face, and much nearer to the fibula than to
the free side of the bone from which it derives its name. The aponeu-
rosis which covers it, and touches it almost immediately, is striated, lustrous,
and strengthened with very strong longitudinal fibres. Farther up it is con-
cealed bv the tibial portion of the soleus muscle, the inner head of the gas-
trocnemius, the superficial aponeurosis, and the subcutaneous stratum, in
which are bedded the saphena vein and the corresponding nerve.
It is but seldom that the posterior tibial is wanting, but it may happen that
it is very small, and that the peroneal takes its place in supplying the sole of
the foot. It is more common to see it keeping the meaian Tine until it
approaches the malleolus. The nerve is in such cases on its inner side. I
observed it on one occasion to proceed side by side with the peroneal for two-
thirds of its whole length, and then to enter the hollow above the heel at
nearly an inch behind the malleolus.
Art. 2. — Surgical Remarks.
Like the anterior tibial, and for the same reasons, the posterior tibial artery
is but rarely the seat of spontaneous aneurism, or even of false aneurism,
whether diffuse or circumscribed. But Ruysch cites an instance of aneu-
rism near tlie heel, which could have arisen from no other artery, and which
was opened for an abscess. Dr. Dorsey has observed a varicoid dilatation of
this artery accompanied by hypertrophia, in a case of varicose aneurism,
Guattani likewise sneaks of pulsatile tumors, which were evidently the result
of some lesion in tlie posterior tibial : Wounds of this vessel, accompanied
by hemorrhage or diffused aneurisms, have been observed of late, by Messrs,
Scarpa, Hodgson, Marjolin, Dupuytren, Earle, and others.
The ancient method, according to M. Boyer, is the only one which should
be applied to these affections ; because, by the method of Anel the blood would
certainly be returned from below, through the plantar arch and the anterior
tibial artery. Others harboring the same fears, but unwilling to operate upon
a diseased part, have proposed an intermediate method, that is, to place a
ligature above and another below the aneurism, without touching the tumor.
For my own part I cannot see the necessity for such a procedure. Supposing
that the reflux of the blood should prove a hindrance to the cure, it appears to
me, that in order to prevent it there needs only the application of accurate com-
pression upon the passage of the anterior tibial arterv in the foot, as practised
by M. Marjolin, or even just below the wound, if its situation will permit.
And when the seat of the disease is in the sole of the foot, and when com-
OPERATIVE SURGERY. 75
pression lias not succeeded, it is plain that the ligature of the trunk of the
tibial can be practised only according to the modern method. The only case
where the ancient operation would be requisite, or at least preferable, is when
the aneurism lies in the superior half of the leg, and here many will prefer
the ligature of the popliteal, or the femoral itself. Traumatic diffused aneu-
risms are not subject to this rule, and should be treated as they have hitherto
been by Boyer and Guthrie, that is by the method of Keisleyre.
Art. 3. — Manual.
At whatever point the posterior tibial artery is to be exposed, the leg should
be flexed and laid on its external side. If compression is necessary, it should
be applied in the thigh, or upon the body of the pubis.
1st. Behind the Malleolus. — The operator makes a slightly curved incision,
concave anteriorly, beginning an inch above and ending an inch below, and
fassing at least three lines from the posterior edge of the malleolar projection,
n operating upon the beginning of the calcanear furrow, it is necessary to
proceed with much caution, to cut the tissues by laminae, and to pass the
grooved sound under the aponeurosis before dividing it with the bistoury, if
we would avoid wounding the artery, which is here sometimes very super-
ficial. An incision nearer to the malleolus would involve the risk of falling
upon one of the fibro-synovial sheaths, which it contributes to form, and
nothing can be more dangerous than such a mishap, on account of the inflam-
mation which might result. Farther back the artery would be difiicult to
find, and the operation much more laborious. For the rest, after having iso-
lated the vessel from the adjacent parts, it is immaterial whether it be raised
with the sound from the inner or the outer side.
2d. Below the Calf. — In order to discover the posterior tibial between the
malleolus and the calf, a straight incision is made, from two to three inches
in length, at equal distances from the inner edge of the tibia and the tendo
Achilles. The skin, the adipose stratum, and the superficial layer of the apo-
neurosis, having been divided, the next step is to denude with the sound the
deep-seated aponeurosis. An incision is then made through that membrane
of the same extent with that in the skin, the bistoury being carried only in the
groove of a director. The operator will here be sure to meet with the artery,
particularly if he has taken the precaution to cut the tissues perpendicularly,
that is to say, by carrying the bistoury forwards and outwards, as if to striice
the peroneal side of the tibia. It is necessary here to observe that if the
incision of the integuments is commenced nearer to the bone than above
directed, there will be only one, instead of two aponeurotic layers to tra-
verse; but then, in falling upon the muscles at a great distance from the
artery, there is a greater risk of error, than by the method previously-
directed.
Sd. On the Calf of the Leg. — Mr. Guthrie upon one occasion proceeded
to seek for the posterior tibial, by penetrating through the whole thickness of
the calf. Gelee, in a similar case, made a counter incision, passed a ribbon
between the muscular beds and tied it over the fore part of the limb, which
he protected with compresses, having previously insinuated pieces of lint
deeply into the wound between the muscles and the artery, for the purpose
of directing upon the latter a sufficient compression. His patient recovered.
But most authors recommend to penetrate by the inner side of the leg, and to
detach and turn outward the corresponding portion of the soleus muscle and its
aponeurosis, from the posterior face of the tibia. By this method, however, the
10
T4 NEW ELEMENTS OF
operator is exposed to the risk of denuding the bone, of being unable to pene-
trate to the artery without considerable difficulty, and of meeting so much
opposition from the muscles, as to oblige him, after the operation, to divide
their fibres crosswise upon the outer lip of the wound, as occurred to Mr.
Bouchet, of Lyons. By proceeding in the following manner the inconve-
niences above-mentioned will be avoided.
Th^ surgeon placing himself on the outside of the limb, makes an incision
of about four inches in length in the direction of the inner edge of the tibia,
and at a good finger's breadth from it, draws aside the saphena vein, divides
the aponeurosis, and falls perpendicularly upon the fibres of the soleus
muscle, which he incises, layer by layer, as if to gain the posterior face of the
tibia, near its outer border 5 he soon exposes a fibrous bed, thick, white, and
shining, into which the fleshy fibres are inserted — it is the deep aponeurosis,
traversed by many vascular branches. The artery is immediately below it,
enveloped by its veins and accompanied by the nerve, which may be distin-
guished by its roundness, its size, and its yellow color.
D. Peroneal Artery.
The peroneal artery rarely, except in its superior half, claims the assist-
ance of the operative surgeon. Below it is too slender and deeply situated,
to be susceptible of much relief when injured. In cases where aneurisms
develop themselves upon any point of its course, of which the practice of the
Hotel Dieu last winter offered an example, the best mode of procedure would
perhaps be to tie the popliteal or the femoral, rather than the diseased trunk
itself. But if some particular circumstances should render a contrary course
of conduct necessary, the following seems to be the most eligible method to
be pursued.
Operation. — As it would be necessary in the calf of the leg to seek the
peroneal artery at the depth of several inches (whether the operator imitate
the practice of Mr. Guthrie or follow the rules given for the posterior tibial)
and as in the lower fourth of its course this vessel is not of any importance,
it is only at the place where the soleus muscle separates itself from the gas-
trocnemius, that we should think of tying it. An incision three inches in
length, parallel with the posterior ed^e of the fibula, directed toward the axis
of the limb, comprehending the skin, the adipose stratum, the superficial
aponeurosis, the external origin of the soleus muscle, and the deep aponeu-
rosis, would serve to expose it and to isolate it in the substance, or on the
posterior and internal face of the long flexor muscle of the great toe. Mr.
Guthrie, who has declared himself an enemy to the method of Anel in
traumatic aneurisms, in order to reach the peroneal artery, which had been
wounded by a ball, preferred cutting vertically into the calf of the leg to the
extent of seven inches, dividing crosswise the extreme edge of the wound,
and afterwards encircling it with a mediate ligature, by means of a suture
needle instead of attempting to discover the artery above. I am of opinion,
that in such a case it would be better to follow the plan of Guthrie than to
tie the trunk of the femoral.
For all these ligatures, M. Lisfranc recommends that the incision of the
integuments should cross the direction of the artery at an angle of 35 decrees,
instead of being parallel to it. *'By this expedient," says he, '^wiU be
obtained greater facility in holding aside the lips of the incision, and an
almost absolute impossibility of missing the artery." This modification may
be adopted without doubt, and would perhaps be preferable in particular
OPERATIVE SURGERY. 75
instances ; but it does not appear to have sufficient advantage over the ordi-
nary practice to deserve a more particular recommendation.
E. Popliteal,
Art. 1. — Anatomical Remarks,
The ham, much noticed in surgery during the last century on account of
its principal artery, is an excavation in the form of a lozenge, formed of two
triangles, with a common base, and of which the larger part is placed above
the condyles of the femur. Here the Sartorius, semitendinosus and semi-
membranosus muscles, together with the adductor magnus, form its internal,
the biceps the external, and the femur the anterior wall. In the portion
lyino; in the leg, the origins of the gastrocnemius and the condyles of the femur
limit it upon the sides, while the posterior face of the articulation and of the
popliteus muscle form its floor. Lastly, an aponeurosis, with transverse fibres,
sometimes of considerable strength, continuous with those of the thigh and
leg, closes this whole space from behind.
The popliteal artery traverses its length from above, inclining a little
nearer to its inner edge (which conceals it in the upper part of the space)
than to the outer edge, as far as the point, where it passes into the fossa be-
tween the condyles. In the femoral part of the space, the vein is strongly
united to the artery behind, and to the outside ; the internal branch of the
sciatic nerve is still more superficial, and four or five lymphatic ganglions,
with some cellular tissue and fat, surround the vessel and separate it from
the aponeurosis. On the leg it is less deeply situated ; the vein and the
nerve are frequently found on the inside; at other times the former lies on
the peroneal side, while the latter is on the tibial. Its fatty cellular tissue,
and a little lower down, the origins of the gastrocnemius conceal it from
behind while its anterior surface rests on the posterior ligament of the articu-
lation and the popliteus muscle. It is well to add, that the external saphena
vein ceases to be superficial when it enters this region, on the median line
of which it is generally observed, and that it empties a little above the con-
dyles into the popliteal vein.
Art, 2. — Surgical and Historical Remarks,
In no part is aneurism more common than in the ham. Spontaneous aneu-
rism is that to which it is particularly subject. Traumatic alieurism is also of
frequent occurrence, and varicose aneurism is sometimes met with. The
great frequency of the first has much occupied the attention of surgeons.
Some have attributed it to efforts at the extension of the leg upon the thigh.
Scarpa, M. Delpech, and others, oppose this opinion, and maintain that aneu-
rism which is not the immediate consequence of a direct wound, is always
produced by a disease of the internal or middle tunic of the artery. M.
Kicherand thought to solve the problem in favor of the opinions of the former
surgeons, by the following experiment. He took the lower extremity of a
dead subject, which he briskly forced to its greatest possible extension by
acting on its two extremities, whilst the knee, or middle and convex part, wa»
supported on a solid body. Dissection afterwards showed the internal coats
torn and bruised in several places. But Mr. Hodgson mentioned experiments
which have been attended with opposite results, and the greater part of
modern practitioners adopt the opinion of Scarpa. Has this question ever
76 NEW ELEMENTS OF
been presented in its proper light? Would it not be possible to reconcile the
two modes of viewing it ? It is true, that whilst the artery is perfectly sound
no extension of the leg appears capable of breaking its coats ; but if its inte-
rior is incrusted with calcareous plates, or is the seat of ulceration ; if one
of the membranes has lost its flexibility and has become brittle, why reject the
explanation of M. Richerand ? It is laborious men — those who are always
€rect, jockeys for example — that most frequently present this malady.
The form of the popliteal aneurism, the effects that it produces, and all that
concerns its development, find a very natural explanation in the anatomical
disposition above described. Arrested by the bones in front, and by the apo-
neurosis in the rear, the tumor extends itself at first in length andi breadth,
and remains for a considerable time without external prominence. Thus con-
fined, it presses upon the lymphatic ganglions, the vein and the nerves, and
occasions swelling, infiltration, pain, numbness, and sometimes gangrene of
the leg. The pressure which results from it may also determine the absorp-
tion of a part, or even the whole of the thickness of the bones, of which several
examples are cited. Most frequently, however, the aponeurosis yields and
becomes thinner, and the aneurism comes to project under the skin, without
producing all these evils.
Anatomy teaches us, that the seat of the opening in the artery cannot be cor-
ectly ascertained by the point occupied by the external tumor. The resist-
ance offered by the soft parts of the popliteal regions being less in the middle,
than in any other part, it is evident that here the aneurismal cyst will always
tend to project. If then the ulceration take place in the tibial angle of the
space, the aneurism will nevertheless make its appearance above the condyles ;
and if on the contrary, it occur in the superior angle, it will be seen gradu-
ally to descend. This is a point which ought always to be kept in view in
practice, at least in operating by the ancient method.
The anastamoses by which the arteries of the leg communicate with each
other are so numerous and large, that the surgeon need not be under the
slightest apprehensions with regard to the re-establishment of the circulation
in that part of the member after the operation for aneurism, but in the hollow
of the ham the operation is not attended with the same certainty. There the
artery is alone, and the supplementary branches are very small. The older
surgeons, persuaded that the obliteration of such a trunk would produce mor-
tification of the parts which were nourished by it, had no other resource, after
the use of compression and a weakening regimen, but the amputation of
the thigh. Even J. L. Petit, and Pott, labored under these apprehensions.
N. Guenaud vainly endeavored to remove them. If any more fortunate results
were announced, it was said that they were produced by an irregular distri-
bution of the arteries ; no one durst believe tnat the blood could arrive at the
leg after the ligature of its only arterial trunk ; and it required the operations
performed by Guattani, Pelletan, Desault, Hunter, &c., and above all, the
researches or the laborious Scarpa, to give prevalence to the opinion opposed
in the beginning of this century. At the present day, however, there no
longer exists any uncertainty upon this point, and popliteal aneurism is now
attacked with almost as much confidence as that of one of the tibial arteries.
Nevertheless, it would be wrong to dissemble that this operation is a very
serious one, and ought not lightly to be attempted. In this, as in aneurisms
of the superior third of the leg, 1 should prefer the old method, or even that
of Brasdor. .
The enfeebling regimen applied to aneurisms of the popliteal artery, is a
resource too dangerous and uncertain to be seriously recommended. Cold
OPERATIVE SURGERY, 77
applications — ice or clay, used topically — so highly spoken of by M. Kalm-
ski, have not been very successfully used, excepting by Messrs. Guerin and
Dutrouilh, of Bordeaux. Mediate compression, either upon the tumor itself,
above it, or over the whole limb, has been attended with results more advan-
tageous. Guattani, Messrs. Boyer, Pelletan, Richerand, Ribes, Dupuytren,
Viricel, &c., cite examples of cures obtained by these means. But eleven
months of care and absolute rest were required for the recovery of the patient
under the treatment of Eschard, besides, these cures are rare. M. Roux
mentions a case where compression, directed successively upon different parts
of the thigh, was followed by the most lamentable effects, and that without
arresting the progress of the aneurism. Compression may, notwithstanding,
be used upon young, feeble, or timid subjects, who have a great repugnance
to an operation, remembering always that it should be combined with refri-
gerants and the treatment of Valsalva.
If the patient is unable to support it, and it aggravates instead of amelio-
rating the symptoms, it is easy to remove it and to have recourse to other
methods. When the disease evinces a disposition to disappear spontaneously,
it cannot be denied that compression will powerfully assist the salutary
efforts of the system. In such cases, at least, it is likely to be attended with
success. Sometimes the tumor has disappeared without surgical assistance.
M. Trousseau relates the case of a countryman who was admitted into the
hospital at Tours, with an aneurism in the ham. A consultation of the prin-
cipal surgeons of the city took place, and the necessity of an operation was
unanimously admitted. The next day, however, the pulsation in the tumor
was found in a great measure to have subsided ; three days afterwards it was
not to be felt, and at the expiration of two months the patient found himself
perfectly restored, without having undergone any operation whatever. M.
Blizard and M. Salmade give each a similar example ; and the records of
the science contain several others not less remarkable.
As to the ligature, it would seem by a letter from Testa to Cotugno, that
Keisleyre had used it many times before it was discussed in Italy. Loch-
man, another surgeon of Lorraine, also practised it successfully upon a pa-
tient at Florence, in 1752 ; and Burchall ventured to do the same at the
Manchester Infirmary, in 1757. These facts, no doubt, were what awakened
the attention of Mazotti and Guattani. In two operations performed by
the former, he placed a second ligature below the perforation in the artery ;
and it was with this modification that the practice of Keisleyre was attempt-
ed for the first time amongst us by Pelletan, in 1780.
If requisite, the popliteal artery might be tied according to either of the
three known methods. The old method has been very frequently resorted to
in France, by Pelletan, Desault, Deschamps and Boyer, but presents so many
difficulties that it has been very little practised during the last ten or fifteen
years. It is rarely, also, that Anel's method, strictlv taken, can be applied
to aneurisms of the ham. Desault is the only one that has so used it ; and
his experience tends to prove that it is infinitely better to tie the femoral
itself. Although the plan recommended by Brasdor has never yet been tried,
I do not think proper in this place to pass it unnoticed. In fact, if the tu-
mor has not too much deformed the part, is not too voluminous, occupies the
femoral portion of the popliteal space, it appears probable that the ligature
might sometimes be placed below the diseased part. Nevertheless, as the
operation would thus become a little more difficult than if performed upon
the thigh, without securing any very manifest advantage over either of the
other methods, it is for experienced and enlightened surgeons to decide upon
?B NEW ELEMENTS OF
the propriety of its adoption in certain cases. It is only then in aneurismal
affections of the superior third of the leg, that ligature of the popliteal artery
will be found advantageous ; Anel's method is therefore the only one in
' which it can be practised. It need not after all be attended with much diffi-
culty ; perhaps it ought even to be preferred when the patient is of a spare
habit, and when every tiling indicates that the disease does not extend so far
as tlie ham.
Art. S. — Manual,
1. Ordinary Process. — The patient is laid prostrate, and the leg is mode-
rately extended. To reach the artery in the lower part of the popliteal space,
an incision is made through the skin and subcutaneous layer in the median
line, parallel with the axis of the member and three or four inches in length 5
care being taken to push outwards the external saphena vein if it presents it-
self under the edge of the bistoury. The aponeurosis once divided, the cut-
ting instrument becomes useless. The cellular tissue and the fat are then
cautiously torn ; the fibres of the gastrocnemius are pushed aside, and the
vessel is separated from its vein or veins by means of a grooved director.
Above the Condyles it is more easy to avoid the saphena. The incision should
be longer, a little nearer to the inner than the outer side of the ham (at least
high up), and to follow a slightly oblique direction, so as to come over the
fossa between the condyles. Beneath the aponeurosis are the nerves ; a
little deeper the veins ; and, quite at the bottom, the artery ; which it is
usually very difficult to separate from the vein, and which is always here more
deeply situated than in its inferior half.
2. Process of Messrs. Johert and Ashmead. — A new method, totally dis-
tinct from the preceding, has been invented by one of my fellow-students.
Instead of making an incision upon the posterior surface of the popliteal ro-
gion, M. Jobert recommends that the artery should be sought by penetrating
in the depression that may be observed when the leg is half bent above the
internal condyle of the femur, between the vastus internus and the inner
border of the ham. By this method it appears to me that difficulties are created,
which do not exist in the ordinary mode of procedure so long as the operator
keeps in view the anatomical disposition of the parts. I do not think, there-
fore, that the modification of M. Jobert ought to be adopted, notwithstanding
the more precise rules to which Mr. Ashmead (who believed himself to be
the originator of this method) has since subjected it.
Results of the Operation. — Whatever may have been the means, method, or
process, by which a cure has been occasioned, the effiarts of the organization
m re-establishing the circulation of the blood are always the same. The oblit-
eration of the vessel extends to a certain distance above and below the wound
or part compressed by the ligature; the branches which keep up the commu-
nication between the perforating arteries and the superior articular branches,
together with some branches of the superficial femoral, and the inferior
articular arteries, the gastrocnemial and the recurrent tibial, augment gradu-
ally in volume, and at last form a beautiful net-work round the articulation.
The blood then passes easily from the thigh into the arterial canals of the leg.
There is, in the Museum of the Faculty, an anatomical preparation taken
from a patient cured a long time before by Sabatier. A drawing of a similar
preparation may also be found in the first volume of the Clinique of Pelletan.
Messrs. A. Cooper, Hodgson, Dupuytren, &c., have also observed the same ;
and I had an opportunity of assuring myself of its reality, on the body of the
OPERATIVE SURGERY. 79
first one upon whom the ligature had been applied at Paris for popliteal aneu-
rism. It was in 1780 that this patient placed himself under the care of M.
Pelletan. He was then thirty-two years old, and died at the a<j;e of eighty-
four. The trunk of the popliteal artery was transformed into a fibro-cellular
cord, quite slender and pliant, through almost its whole extent; the superior
articular arteries, internal and external, the anostomica magna and a branch of
the superficial muscular, furnished by the femoral, were of the size of large
crow-quills, and formed large and irregular arches, upon the sides of the
patella and the condyles, by communicating with the recurrent branch of the
anterior tibial, the inferior articulars, &c. The limb was in good case, and
did not differ in any respect from that of the opposite side.
F. Femoral.
Art. 1. — Anatomical Remarks.
The femoral artery extends from the crural arch to the beginning of the
inferior third of the thigh, and follows a line somewhat spiral, descending
from the middle of the fallopian ligament obliquely inwards to the space be-
tween the condyles of the femur, where the continued trunk is called the
popliteal. The vein, lying on its internal and posterior side, is united to it
by dense cellular tissue, which forms for both a sort of common sheath. The
principal branch of the crural nerve, which at first lies upon its external side,
inclines by degrees as it descends towards its anterior surface, and some-
times to its internal side ; but farther down abandons it altogether, to pass
between the muscles which form the side of the ham. Another nerve, not less
voluminous, sometimes crosses its superior part, lying before it and the vein,
as far as the middle of the thigh. A fibrous sheath, hollowed from the thick-
ness of the deep layer of the fascia lata, envelopes the whole, and presents a
disposition of parts which merits particular attention. The interior wall of
this sheath gradually increases in thickness as it descends ; for at the groin it
may be easily torn with the sound, while below it often presents very dis-
tinct transverse fibres, a pearly appearance, and great resistance. At its
lower extremity, it is continuous with the fibrous expansion, or more properly
with the aponeurosis given off by the termination of the second rather than of
the third adductor. The artery is next covered by the sartorious muscle,
which crosses it very obliquely from the outer to the inner side, and conceals
in reality only the two inferior thirds. In the superior part the artery is covered
by the deep lymphatic ganglions, and by clusters of filamentous cellular tissue.
It is only when the sartorius approaches the gracilis muscle to form the apex
of the inguinal triangle, that its internal edge begins to separate the artery
from the superficial layer of the aponeurosis of the thigh, which almost touches
it in the bend of the groin. As we proceed towards the skin, after the sarto-
rius muscle, comes the first lamina of the fascia lata, pierced in the upper part
by one or more openings for the entry of the superficial veins into the deep
femoral, then the subcutaneous stratum which contains the branches of the
saphena vein, which latter is almost always situated within the line of direc-
tion of the artery.
Among the branches of the femoral, there is a certain number which ought
not to be forgotten by the surgeon, viz. 1st. The profunda, which separates
itself from the femoral about two inches below the ligament of Poupart, buries
itself in a line with the lesser trochanter beneath the deep layer of the apo-
neurosis, and divides into the three perforant branches. 2dly. The circum-
80 NEW ELEMENTS OF
flexes, which proceed sometimes from above, sometimes from beneath, and
frequently from the profunda itself. Sdly. The superficial muscular, given
off by the external circumflex and descending to the knee to form anasto-
moses with the branches of the popliteal. 4thly. The anastomica magna,
which has its origin near the commencement of the popliteal, and proceeds
towards the inner side of the leg along the superior surface of the third ad-
ductor.
Ano7nalies. — -The secondary branches of the femoral are subject to nume-
rous anomalies, but the trunk itself presents very few. Morgagni, who
believed it to be often double, merely supposed it but never really observed it.
Haller, the same. But Gooch cites three examples; Cassamayer mentions a
fourth ; and I have myself met with a fifth. In my own case the supernu-
merary artery was evidently only a continuation of the profunda, which, after
having supplied the perforating arteries, preserved sufficient volume to enable
it to descend below the knee. In a subject aifected with aneurism, Mr.
Charles Bell found the femoral artery divided into two trunks of equal size,
which united to form the popliteal.* Mr. J. Houston, conservator of the
anatomical museum in Dublin, cites a similar fact. Messrs. Bronson and
Cromwell, distinguished young physicians of America, pointed out to me in
1825, in the pavilion of the practical school, a different variety. Instead of
remaining contiguous to the artery, the crural vein was, on the contrary, sepa-
rate from its commencement, and did not rejoin it until its entry into the
popliteal space, after having formed a long arch the convexity of which looked
towards the internal edge of the thigh. I liave once since met with a similar
disposition.
Art. Z. — Historical and Surgical Remarks,
If spontaneous aneurism is more common than any other in the popliteal
space it, is not so at the thigh ; although even there it is not of very rare occur-
rence, particularly in the upper part where the artery, badly protected in front,
is obliged to follow the different movements of the articulation. All its other
parts may also be the seat of spontaneous anuerism, but the thigh is more
particularly subject to traumatic aneurism. Diffused and circumscribed
false aneurisms often occur there ; nor is this part exempt from varicose
aneurism as has been proved by the observations of M. liarrey, and by a case
which was treated at the Hotel Dieu, in 1824, by M. Guersent, jun. In
the lower part the sartorius muscle has a tendency to force the tumor for-
ward ; in the superior part it often pushes it inward ; this, added to the thin-
ness of the aponeurosis, rent the fallopian tube, and explains the remark which
has been made by so many practitioners, viz : that in the eroin the opening
of the vessel almost always corresponds with the inferior tliird of the aneu-
rismal bag. As they are not surrounded by solid parts, aneurisms of the
femoral speedily enlarge ; yet, as they comprise neither voluminous nerves
nor important articulations, they are, other things equal, attended by fewer
unpleasant symptoms than aneurisms of the popliteal artery.
Spontaneous Recovery. — Aneurisms of the thigh, notwithstanding the size of
the artery which gives them birth, are not always fatal. M. A. Severin re-
lates a case where the tumor was attacked by gangrene. After the fall of
the eschars, the wound cicatrized by degrees; there was no hemorrhage,
and the limb returned to its natural state. Lancisi saw an aneurism, which,
though very voluminous, decreased by degrees, and finally disappeared
Tinder the influence of simple fomentations, tepid baths, and diluents. Guat-
OPERATIVE SURGERY. 81
tani saw, at Rome, in 1765, a similar case to that mentioned by M. A. Severin.
Clarke, in 1784, witnessed another. Ford saw an aneurism of the thigh cured
without other assistance than that afforded bj spare diet and rest. Mr. Spal-
ding, in 1808, after having opened and cleansed an enormous crural aneurism,
was astonished to find the artery completely obliterated above and below the
lesion, and not a drop of blood to issue from either end. Mr. Hodgson, in
operating upon a dead subject, encountered an aneurismal bag in the inferior
third of the thigh, the coagulum of which, extremely solid, had completely
obliterated the artery as far as the origin of the profunda, in one direction,
and to the commencement of the leg in the other. Finally, M. Marjolin, in
his lectures before the faculty, makes mention of a man aged sixty, afflicted
with an aneurism of the middle of the femoral, which transformed itself into
an abscess, and disappeared after a long suppuration. Mr. Guthrie cites a
similar example, which took place in the York hospital.
But these cases ought to be considered only as happy exceptions, on which
it would be imprudent to count in practice.
The refrigerant method, antiphlogistics, regimen, and compression, have
also produced favorable results. Hodgson adduces numerous examples. At
Bordeaux, M. Teyran cured a femoral aneurism by bleeding, cold applica-
tions, &c., on a patient who had another aneurism on the opposite side. M.
Larrey speaks of a sergeant of the guards, who received, in April 1817, a
stroke from a sabre in the superior part of the right thigh; a circumscribed
false aneurism was the consequence, which was speedily cured by the treat-
ment of Valsalva, aided by the action of topical refrigerants. M. Ribes
reports that Sabatier succeeded by the same means with a patient who was
afflicted with two aneurisms upon the same limb— one upon the thigh and the
other upon the ham.
Compression. — The observations of Arnaud, Mayer, Kinglate/Albers, and
MM. Dubois and Dupuytren, prove that simple compression is capable of
producing the same results. For this purpose Heister, Senf, Foubert, Rava-
ton, and Camper, constructed machines more or less analogous to the tourniquet
of J. L. Petit ; and it was for the same that Guattani and Theden so earnestly
recommended their particular form of bandages. If such means cured aneu-
rism without obliteration of the artery (as was believed until the expiration
of the last century), they certainly ought to be tried before resorting to the
ligature ; but, since the contrary has been so abundantly proved by Scarpa, it
will be found far better to have recourse immediately to the latter.
"ligature. — Ligature of the femoral is now very frequently practised. It
is usually preferred, as we have seen above, in treating lesions of the popliteal
artery, and even aneurisms of the leg. Many centuries elapsed, however,
before any one dared to practice it. It was well known that Severin and
Trullus had operated successfully for an aneurism situated at eight fingers'
breadth below the groin ; that Bottentuit had done the same at the Hotel
Dieu, at Paris, in 1688 ; that Guattani had used mediate compression at the
passage of the artery under the fallopian ligament with equally complete
success, but nothing was then able to open the eyes of surgeons. It was
only after having deeply reflected upon the numerous anastomic branches in-
dicated by Winslow and Haller, that Heister ventured to propose ligature in
certain cases of aneurism. A short time afterwards, Anel, Hamilton, Burs-
chall, Leber, Jussy, &c., became convinced that, after the ligature, the cir-
culation of the blood soon re-established itself in the inferior part of the limb.
As the experiments that were made in England from 1760 to 1780 were,
according to Pott, Wilmer, and Kirkland, much less encouraging than they
11
82 NEW ELEMENTS OF
had been twenty years before in Italy, it required nothing less than the suc-
cess of Desault, Hunter, and Pelletan, to bring it into honor, and cause its
general adoption
The ligature may be used at any point in the length of the thigh ; but not
at all points with the same chance ot success. As long as the profunda femoris
is respected, the danger is not greater than when the operation is practised
upon the popliteal artery. But when it is necessary to sacrifice the great
muscular artery, it is evident that the blood can only reach the limb by the
secondary branches which emerge from the pelvis. Of the three methods
generally known, that of Anel is almost the only one now practised. That
of Keisleyre, so frequently used by Desault, Pelletan, Deschamps, Messrs.
Boyer, Roux, &c., and which prevailed so long in France, is no longer re-
commended, even by M. Boyer himself, in the second edition of his work,
except in a few particular cases. Are there really any circumstances under
which it ought to be preferred ? The cases mentioned by Hodgson, and those
which have occurred in England during the last thirty years, seem to prove the
contrary. Nevertheless, some individuals of an imposing authority among
us, have continued to use it in cases of varicose, and in diffused traumatic
aneurism; particularly when the arterial tumor approaches so near to the
bend of the groin as to render it impossible to place a ligature between it
and the profunda. In 1826, I saw an operation performed in this manner by
M. Roux, for an aneurism of the thigh. It was successful. It is also true, as
has been observed by M. Boyer, that if the tumor extends itself to the bend
of the groin, v/e may by opening it preserve the profunda.
It remains to be seen whether this advantage is sufficient to counterba-
lance the numerous inconveniences to which this method exposes us. Ligatures
of the iliac have proved, that in such cases as the above the muscular artery
is not indispensable to the maintenance of life in the limb. What regret, too,
would a practitioner experience, if, after having emptied the aneurismal bag
he found the femoral opened higher up than he had supposed ; or that the
walls of the superior portion were too much diseased to bear the action of the
ligature !
It is not absolutely necessary, then, to open the aneurismal bag, for the
purpose of tying the crural artery in any part of its length, except in aneu-
risms from external causes, or those which are diffused, or very voluminous
and elevated.
In applying the method of Anel to the treatment of aneurisms of the infe-
rior member, Desault aimed for the upper part of the popliteal space, and not
Upon the femoral artery, properly so called. M. Martin, of Marseilles, says
that Spezzanni, an Italian professor, practised this mode of operation upon the
thigh four years before, with the intention of disarticulating the leg when
the gangrene should have become limited, and that the patient preserved his
limb.
It is affirmed, on the other hand, as I have already stated, that many years
before the merits of the ligature were canvassed in England, Brasdor recom-
mended it publicly in his lectures in the schools of surgery. To Hunter,
however, unquestionably belongs the merit of having first caused to be felt
the importance of such a modification in the treatment of aneurism, and of
having awakened the attention of the surgeons of Europe to this happy im-
provement. Hunter made his incision a little below the middle of the thigh,
upon the internal border of the sartorious muscle, exposed the artery to the
<«xtent of three inches, and then tied it with four ligatures.
Scarpa says that the operation should be performed at four fingers' breadth
OPERATIVE SURGERY. 83
from the ligament of Poupart 5 that the vessel w^ill then be most easily found;
that there will be no important collateral artery to avoid; and that in operating
as far as possible from the aneurism, there will be a greater probability of falling
upon a healthy part of the tube, which shall be able to support the ligature.
The reasoning of Scarpa has not been universally admitted. The greater
part of the French surgeons are still of opinion that, in treating aneurism of
the popliteal artery, it is useless to go so high up as the inguinal space, nor
even for aneurisms of the thigh, unless the seat of the disease renders it neces-
sary. They rarely proceed so high, lest by approaching too near to the pro-
funda they should hinder the formation of the coagulum. It is, therefore, still
proper to lay down the method of tying the femoral artery in the two principal
points of its extent ; that is to say, above and below its middle part.
Art. 3. — Manual,
§ 1. Inferior Half,
The member is at first slightly bent and turned outwards, in order to place
the muscles in a state of relaxation. An incision of about three inches in
length is then made in the soft part, at such a point that half the incision shall
be in the middle and half in the inferior third of the thigh. In cutting lower
down, at three or four fingers' breadth above the knee, as some have
recommended, +he artery will not be found, as it there enters the cavity of
the ham. In operating higher up, we trench upon the process of Scarpa.
In the* operations of Hunter, this incision, oblique from without to within,
fell upon the internal edge of the sartorius muscle, which was turned forward
for the purpose of exposing the sheath of the vessels. The operator will then
successively encounter the skin (generally rather thin), the adipose stratum,
the saphena vein, which must be carefully avoided, the superficial lamina of
the aponeurosis of the sheath of the sartorius muscle ; and beneath this, deeply
situated, near the femur, in the furrow which separates the vastus internus
from the adductors, a second fibrous bed, to be divided.
M. Roux, on the contrary, advises that the incision should be made on the
external edge of the anterior muscle, which should be pushed inwards so as
to enable the operator to come at the artery. The same method was also
recommended by Hutchinson, in 1811. *'Byit," says he, *'the saphena vein
will certainly be avoided, and there will be just the same number of beds to
divide as by the procedure of Hunter."
Considering that in both ways it is necessary to displace the muscle which
hides the vessels, turning or pushing it either inwards or outwards, Mr. Hodgson
thinks that it would be better to discover the middle third of the artery, an
opinion which had been already advanced by Desault, who also asserted that
we may, without any bad result, cut across the fibres of this muscle whenever
it embarrasses either by its presence or its contractions.
M. Lisfranc adheres to the principles of Hunter, and gives as his reasons
for so doing, that an experienced surgeon cannot be arrested by the saphena ;
tiiat by Hunter's method the wound is not so deep ; and that being placed
near to the internal edge of the thigh, it is easy, after the operation, to give
it a dependant situation, and thus prevent the stagnation of fluids between its
lip&. These motives are certainly laudable, and ought to be allowed some
importance. It may, however, be objected, that all practitioners are not
equally skillful ; that a wound, if inflicted upon the saphena, although not
in itself dangerous, is likely to produce gangrene, if the crural vein should
84 NEW ELEMENTS OF
happen to be included in the ligature or obliterated in any way whatever, as
in the example cited by M. Begin ; that if instead of falling upon the sheath
of the sartorius muscle the operator should expose the gracilis, he would be
very likely to be deceived ; and lastly, that the dependent position so much
insisted upon in theory, may be altogether neglected in this instance without
much inconvenience. The' process of M. Roux, is also liable to some mis-
takes. By inclining the bistoury too much towards the outside, it sometimes
happens that the operator encounters tlie triceps muscle, and that if he do
not speedily perceive his error, the case becomes very laborious and is seldom
terminated without injurious results. To escape these inconveniences, it is
only necessary to remember that the fibres of the sartorius are parallel to
each other and to the axis of the muscle, and also that of the member, and
are without any admixture of fat; whilst those of the vastus internus are col-
lected into fasciculi, mixed with cellular or adipose lamellcB, and are all
oblique, from above to below, from rear to front, and from the internal border
towards the median line of the thigh. However this may be, the wisest
course is, in my opinion, to conform to the advice either of Hodgson or
Desault, by which, after dividing the first aponeurosis, the operator may
arrive with facility either upon the inner or outer edge of the sartorius ; and
afterwards avail himself, with equal advantage, of the practice either of Roux
or of Lisfranc. As to the division of the muscle, recommended by Desault,
although not now thought so dangerous as formerly, it ouglit not to be practised
but upon occasions of absolute necessity. In theory, it is difficult to conceive
that it can ever be required, except in operating by the old method.
§ 2. Superior Half.
Above the middle of the thigh, an incision of about three inches in length
is commonly sufficient to discover the trunk of the femoral. The middle part
of this incision should be four fingers' breadth from the fallopian ligament, un-
less an absolute necessity should exist for making it immediately under the
crural arch, so as to fall between the profunda and the epigastric. In all cases,
the bistoury sliould take the direction of the line represented by the passage
of the vessel, and should incline a little outwardly rather than inwardly,
on account of the saphena. After the skin and the adipose stratum, is seen
the aponeurosis. Before dividing this, it should be recollected, that low
down the internal edge of the sartorius usually separates this lamina from
the artery, which cannot take place in the upper part of the inguinal triangle.
This lamina being opened, and the muscle thrust outwards as far as neces-
sary, the operator passes a grooved director (to serve as a conductor for the
bistoury) under the superficial layer of the arterial sheath, and then makes,
without danger, an incision of the same extent with the external wound.
Finally, he isolates the vessel, taking it on its internal side, and using extreme
caution to avoid wounding the crural vein or the neighboring nerves.
§ 2. Results of the Operation,
After the preceding operation, whether performed high up or low down, the
vessels charged with the re-establishment of the circulation are, in either case,
the same. The branches of the superficial muscular pour their fluid into the
anastomica magna, the external articular, or the recurrent tibial ; and those
of the profunda or of the perforating arteries, into the internal articulars.
The blood sometimes finds its way, by means of the muscular branches inter-
vening between th« ligature and the tumor, preserves the pulsations, and
I OPERATIVE SURGERY. 85
sometimes delays considerably the resolution of the aneurism. This incon-
venience, which at first appeared serious, no longer gives much uneasiness.
Cold and discutient applications, aided by a gentle pressure, will generally
cause the tumor to disappear, when it is not thought better to abandon it to
its own action. Yet facts contradictory of the above are more numerous and
authentic than would be supposed. Mr. Monteith, of Glasgow, has seen the
pulsations reappear several months after an apparent cure. An aneurism,
operated upon by Mr. Gumming in 1821, reappeared in 1825, so as to
render it necessary to amputate the thigh. In a case in which I had tied the
femoral three inches below the profunda, hemorrhage manifested itself at the
coming away of the ligature on the thirteenth day.
When it has not been possible to preserve the profunda, the circulation is
established by the branches of the hypogastric. The gluteal, the ischiatic,
the internal pudic, and the obturator arteries communicate with the circum-
flex and perforating arteries, and the latter then empty themselves into the
arteries which encircle the knee. If those aneurismal tumors which develop
themselves in the substance of the bones — tumors which were first observed
by Pott and Scarpa, of which Pelletan cites several examples, and which have
been observed three times at the Hotel Dieu by M. Dupuytren — if such tumors
should make their appearance on the leg or upon the thigh, it would not be
necessary in all cases, as it was formerly believed, to amputate the limb. The
ligature of the femoral, by Anel's method, would be found sufficient. It was
used with complete success by Mr. Pearson, and M. Lallemand of Mont-
pellier.
Caustics, astringents, styptics, immediate compression, gradual obliteration,
and temporary ligatures, have also been tried upon the crural artery. In the
case of a young and robust man, twenty-two years of age, who labored under
an aneurism of the superior third of the thigh, produced by a sabre-stroke,
Sabatier, after having opened the aneurismal sac and placed two precaution-
ary ligatures under the artery, contented himself with filling the wound with
compresses and a pyramid of agaric, confined with a bandage. His patient was
cured at the expiration of two months. M. Dubois succeeded upon one
occasion, with his compressing forceps (j)ince presse artere), and Scarpa, and
several surgeons of London, have been so fortunate as to be able to remove
the ligature three or four days after having fixed it upon the artery.
G. Ligature of the Circumflexes or of the Profunda.
When one of the circumflexes or the profunda has been wounded, or has
become the seat of aneurism, there is generally little difficulty in applying
the ligature. The essential point is to ascertain such a lesion. By exposing
the trunk of the femoral at the place where it emerges from under the crurid
arch, a thread may be easily applied upon the rest of the affected artery.
M. Roux, however, is the only surgeon who to my knowledge has had occa-
sion to operate upon one of the secondary branches.
H. Exteraallliac.
Art, 1. — Anatomical Remarks,
From the level of the sacro-iliac symphysis, where the primitive iliac artery
divides, to its arrival at the fallopian ligament, the external iliac represents
a line slightly curved, with its convexity looking outward and backward, and
86 NEW ELEMENTS OF
more marked in the female than in the male ; and so much the more as the
pelvis is larger, or the superior strait more depressed. It rests upon the
psoas muscles on the outside, and upon the iliac vein within and behind,
and is covered immediately by an expansion of the fascia-iliaca. The crural
nerve is separated from it by the tendon of the psoas, and by an aponeu-
rosis of great strength. A branch of the genito-crural nerve sometimes runs
along its internal and anterior surface, which is crossed by the ureters, and
in the female by the ovarial vessels. The peritoneum which hides all these
different objects, adheres to it slightly by means of a very loose lamellar and
adipose stratum, and leaves it altogether in front, in order to return upon the
posterior surface of the abdominal parietes. At its entrance into the crural
canal, it again gradually rises, becomes more superficial, and forms new con-
nexions. In this latter position it is supported by the body of the pubis, and
by the origin of the pectineus muscle ; the vas deferens crosses it to bury
itself in the pelvis, and the spermatic cord does the same in passing through
the inguinal canal. The epigastric vein is also obliged to cross the inguinal
canal to open into the iliac vein, which lies attached to it as in the thigh ; the
fibrous lamina which confines it against the psoas and iliacus, here becomes
perceptibly thinner. The circumflexa ilii and, the epigastric (the only branches
which it furnishes) separate from it, the one a little on the outside, and the
other a little on the inside, generally on a level with the linea ileo pectinea, but
sometimes four, six, or eight lines higher or lower. The lymphatic ganglions
which surround it until it reaches the crural arch, and possess the power of
compressing it by swelling, have given birth to apprehensions of disease which
have no foundation in reality. The coecum on the right, and the sigmoid
flexure of the colon on the left, are the only viscera by which it is separated
from the parietes of the abdomen. Nothing is more easy with patients of a
meagre habit, and when all the muscles are in a state of relaxation, than to
establish upon it a mediate compression capable of suspending for the time
the circulation in the limb, as has been demonstrated by Bogros, and as I have
myself proved in the case of a young man who had received a cut over the
epigastric, to which artery I applied the ligature. Its anomalies are almost
exclusively confined to its length, its volume, its curvature, and the points
of origin of its principal arteries. It is possible, however, that it may
consist of two trunks placed side by side, and which pass together under the
crural arch, as was remarked by Mr. James, in a case where he had tied the
iliac artery after the method of Brasdor.
Art. 2. — Surgical and Historical Remarks.
The external iliac artery is seldom the seat of other than spontaneous aneu-
risms. If it were opened in fact by any exterior agent, the hemorrhage which
would ensue would cause the death of the patient before it would be possible
to render him the least assistance. Yet M. Larrey says that he has seen it
in the subject of a varicose aneurism. And since it is not in an exposed
situation, and is not more than four or five inches in length, even aneurism
occurring in it from internal causes can scarcely be very common. The case
of the young man just mentioned who recovered after the operation, is almost
the only one of its species, as will be subsequently seen.
If the fear of gangrene after the obliteration ot a great arterial trunk has
been able for so many ages to restrain surgeons in tlieir treatment of aneu-
risms of the thigh and popliteal region, much more reason is there why they
should reject the mere idea of tying one of the primary divisions of the aorta.
OPERATIVE SURGERY. 87
Facts passed unnoticed, science could not profit by them. In the practice
of Guattani compression was established upon the femoral above the profunda,
and the circulation continued in the Ijmb. Baillie, in a dead subject found
the femoral obliterated as far as the interior of the pelvis, while the inferior
extremity was not in the slightest degree affected. A similar case came under
the observation of Guattani, in 1767 : his patient had labored under an ingui-
nal aneurism, and had been cured by the use of compression. In the dead
body of a patient treated by Gavina, in 1775, the iliac artery itself was found to
be completely impermeable. Similar cases have been reported by Clarke and
others. All these proofs, the injections practised by Guattani, and even those
of Scarpa, which demonstrate the facility with which fluids forced into the aorta
pass into the arteries of the thigh and leg, notwithstanding the previous ligature
of the external iliac, were insufficient, and might perhaps have remained long
unapplied, had not Abernethy been obliged to appeal to them for the first time,
in 1796. An individual who had already undergone an operation according
to the method of Anel for aneurism of the popliteal trunk, came to St. Bar-
tholomew's hospital affected with an inguinal aneurism on the opposite side.
Abernethy applied a ligature below the crural arch ; a hemorrhage, which took
place fifteen days afterwards, left him no other resource than to penetrate into
the abdomen, and to perform upon the iliac artery the same operation which
he had previously performed upon the femoral. The patient expired some-
time afterwards, in consequence of a second hemorrhage. Another operation
performed by Abernethy was attended with the same unfortunate result; but
the third, in 1806, was completely successful. Previously to this period no
one spoke of the possibility of tying the external iliac, without causing the
mortification of the limb ; now it is one of the most common operations in
surgery.
Mr. Freer, in 1806, Mr. Tomlinson, in 1807, imitated Abernethy, and with
like success. Mr. Tomlinson again successfully performed this operation in
1809. Four out of seven patients on whom Sir A. Cooper operated, in 1814,
recovered ; the remainder died, one at the expiration of three months of an
aneurism of the aorta, another from mortification of the limb, and the third
from hemorrhage. M. Delaporte, of Brest, was the first French surgeon who
had the courage to follow the example of the English practitioners ; his
patient died of a putrid fever on the twelfth day after the operation. Messrs.
Goodlad and Dorsey each performed the operation successfully, in 1811 ;
M. Bouchet of Lyons, also succeeded in curing a Spanish prisoner, in 1812;
the latter died the next year of an aneurism of the opposite side. The same
year a patient under the care of M.Albert died of tetanus the twentieth day
after the operation. An old man of seventy -five years of age, in the hands of
Mr. Ramsden, sank on the third day. In 1813, two successful cases rewarded
the efforts of Messrs. Brodie and Norman. Mr. Lawrence succeeded in his
turn, in 1814 ; as also M. Moulaud, of Marseilles, in 1815; but gangrene
occurring on the fourth, destroyed the hopes of Mr. Collier of a similar
result. Messrs. Smith, Sod en, and Dupuytren were less unfortunate : each
saved the life of a patient in 1816. Mr. Cole, in 1817; M. Albert, in 1818 ;
and Messrs. Wilmot, Kirby, Newbegin, and Post, successively added them-
selves to the list. The patient of M. Salmon died on the 16th day. Messrs.
Wright, Richerand, Vacca, Killian, White, Dacrux, and Clot, deserve the
credit of having performed this operation with success. M. Delpech was not
so fortunate ; the patient under his care died in a few davs. M. Tait, in
1825 and 1826, tied successively the two iliac arteries of the same patient,
and with complete success, although on one side the peritoneum was woundeu
88 NEW ELEMENTS OF
in the operation. M. Arendt, in a similar case, left an interval of only eight
days between the two operations, and was equally successful. I performed
the operation myself on the 6th of October. The ligature came away on the
11th day, and the patient was perfectly cured. This case was a remarkable
one. The patient, a young man, seventeen years of age, large and strong,
in clearing a table in a dark place, accidentally forced a butcher's knife into
his groin, and cut across the external iliac artery three lines above the origin of
tlie epigastric ; the blood issued from the wound in torrents. Drs. Layraud
and Durand, who attended almost immediately, compressed the artery at two
inches above the wound, and thus suspended the hemorrhage until my arrival.
Assisted by these two gentlemen and by M. Duvivier, I hastened to expose
and tie the injured vessel. No unpleasant symptoms manifested themselves in
the limb; the emission of urine was somewhat difficult during the second day,
but afterwards became free; inflammatory symptoms about the side during
one week gave us some uneasiness; a first ligature placed very high up with
a curved needle, in order to afford perfect freedom in seeking the seat of the
Avoimd, did not detach itself until the thirty-fifth day; but at length the wound
cleansed itself, and the health of the young man is now perfectly re-established.
This case demonstrates the importance of knowing how to compress the iliac
arteries in the pelvis through the parietes of the abdomen, and proves — first,
that without preventing dilatation of the collateral branches, whether occa-
sioned by compression, as has been proposed, or by the presence of an aneu-
rism, the ligature of the ileo-crural trunk may be practised with success ;
secondly, that the sudden and complete division of that trunk is not abso-
lutely mortal. It is proper, however, to mention that a patient on whom
Beclard operated, in 1822, died of hemorrhage on the thirteenth or fourteenth
day ; and that a similar fate was met by an individual under the care of
M. Dupuytren, in 1823 or 1824. The operation has been successfully per-
formed forty times from the period of its adoption up to the present day.
Art, 3. — Manual.
Notwithstanding the two examples of cure by refrigerants, moxas, and a
weakening regimen, which have been so recently made known by M. Larrey,
the ligature ought always to be preferred in such cases of iliac or inguinal aneu-
rism as will permit its application, and when the patient is willing to submit.
It should be remembered, however, that in carrying it more than three inches
into the pelvis, the neighborhood of the hypogastric renders the operation very
hazardous; so that instead of going as high as the primitive iliac when the
tumor occupies the iliac fossa, and there is not room enough left in the groin
for tying the femoral above the profunda, it will be right to resort to the method
of Brasdor. The patient of Sir A. Cooper lived two months after the opera-
tion ; the pulsations had ceased in the tumor, which was enormous, and it is not
possible precisely to account for his death. In the patient of Mr. James, who
wan not more fortunate, the iliac artery was divided into two nearly equal
trunks. Yet the fruitless attempt of Mr. White, although the femoral was
obliterated below the tumor ; the pulsations which continued to be felt at the
bottom of the wound in the young man whose case has been just related, and
the facts recorded by Mr. Guthrie, prevent us from placing much confidence
in this latter method. To practice it with any possibility of success, it is
necessary at least to be able to place a ligature between the tumor and the
origin of the epigastric arteries and the circumflexa ilii; or else that those
branches should have been displaced by the aneurism filled with coagula and :
OPERATIVE SURGERY. 89
rendered impermeable by the pathological process described by M. Berard.
Numerous processes have been followed for the purpose of arriving at the
external iliac artery.
1. Process of Abernethy. — On the first occasion, Abernethy made an inci-
sion of about three inches in the direction of the vessel above the ligament of
Poupart. This method has been recommended anew by M. Begin, in the
Dict.de Med. et de Chir. Pratique, Upon his second patient, Abernethy,
fearing to wound the -epiga-stric artery, made the incision a little more to
the outside of the inguinal ring, giving it a slightly oblique direction upwards
and outwards so as more easily to avoid the peritoneum.
2. Process of Sir A. Cooper. — Sir A. Cooper made an incision in the form
of a half-moon, in the direction of the fibres of the tendon of the external
oblique — that is to say, with a convexit downwards, and beginning at a little
distance from the anterior superior spinous process of the ileum, and termi-
nating near the inguinal ring; on raising the semilunar flap thus formed, the
operator perceives the spermatic cord, the opening in the fascia transversalisy
and the epigastric artery; by passing the finger beneath the cord, through this
opening, " he will then," says this author, *' easily arrive at the iliac vessels."
3. Process of Mr. Norman, of Bath, and of Mr. Roux. — Mr. Norman con-
tented himself with making an incision la the direction of the fallopian liga-
ment, and afterwards following the directions of Sir Astley Cooper. M.
Roux recommends that the incision should commence a little above, and about
half an inch distant from the spine of the ileum, and terminate upon the
middle of the crural arch.
4. Process of Bogros M. Bogros believes that the method of Sir A.
Cooper, or of Mr. Norman, might be advantageously modified, by directing
the middle of the incision upon that point of the ligament of Poupart whicn
corresponds with the artery, and afterwards gaining the opening in the/a«cta
transversalis, for the purpose of finding with certainty the epigastric, which
■will then serve as a guide to the iliac trunk.
5. Process adopted by the Author, — The following method has appeared to
me the most simple and easy of application. The patient is laid upon his
back, with the limb moderately extended and retained in its position by as-
sistants. The operator then places himself on the side of the aneurism, and
makes a slightly curved incision, three inches in length, parallel with and a
little above the fallopian ligament ; the middle part of the incision is on a
level with the artery. The first stroke of the bistoury passes through the skin
and t\\Q fascia superficialis ; if the flow of the blood from the branches of the
external epigastric artery is so great as to impede the operation, the ligature
or torsion is applied before proceeding further. The aponeurosis of the ex-
ternal oblique next presents itself. For greater security, it is w^ell, though
not indispensable, before making the incision to pass under this tissue a
grooved director. The fibres of the lesser oblique muscle are next seen,
which may be divided without fear by an experienced surgeon with tlie cut-
ting instrument ; otherwise their inferior extremity is to be detached with
the point of a director, pushing them backward and upwards with a certain
degree of force, while the left index finger fixes and retains the inferior edge
of the wound 5 the fascia transversalis is th«n torn in the same manner as ulv
as the spermatic cord, which is pushed aaide in tlie same direction as the
fleshy fibrf^s. From this point, in order to avoid the peritoneum, particularly
when the ligature is to be carried upon a very elevated point of the iliac fossa,
the finger should be used instead of the sound; in otlier cases the latter is
preferable. After having proceeded thus far, if the eye of the operator cannot
12
90 NEW ELEMENTS OF
distinguish the objects, the fore-finger tlirust into the wound, the lips of which
should be kept separate, will easily feel the artery upon the internal edge of
the psoas and the side of the superior strait. By taking it up between
the fingers, as has been recommended by Scarpa and practised by many
surgeons, useless, and sometimes dangerous lacerations are produced. It is
infinitely better to penetrate with the director the sheath which it receives
from the fascia iliaca, directing the beak of the instrument upon its internal
side, and detaching it from the vein by careful movements to and fro.
After this separation, which should be of as small an extent as possible, but
yet should comprise the whole circumference of the artery so as to disunite
it completely from the iliac vein and from the nervous branch which crosses
their surface, the operator, in order to pass the ligature, may make use of
an eye-probe conducted along a director, or of the needle of Deschamps,
or any other convenient instrument. It is better to apply the ligature a little
too high than too low; it is at least necessary to place it above the epigastric.
Beolard is said to have lost one of his patients by having unintentionally
placed the ligature below, instead of above that branch. In consequence of
tliis danger also, and in order to avoid it with greater certainty, Bogros re-
commends the exposure of the epigastric before seeking the iliac artery ; but
in proceeding as I have just directed, where the iliac has been discovered, it
will always be easy to find the epigastric, and to leave it below the ligature.
In order to prevent hemorrhage, or the return of the blood, and the conti-
nuance of pulsation in the tumor, which maybe produced by the artery, some
think it necessary to tie the latter, whether wounded or not, at the same time
with the iliac artery. Though this advice may be followed without much in-
convenience, the practice up to the present time has proved that it is by no
means indispensable. During the operation, but particularly at its termination,
it is of the highest importance that the abdominal muscles be kept in a state of
relaxation, and that the patient should refrain from any effort from making
the slightest movement, otherwise the intestines will certainly present them-
selves at the incision, and a wound of the peritoneum will be the almost inevi-
table consequence ; and although such an injury is not of so much importance
as has been generally supposed, as we see in the instances mentioned by
Messrs. Post and Tait, yet it ought to be guarded against with the greatest care.
Advantages and Disadvantages of the Different Modes of Operation. — The
vertical incision, or that parallel with the artery, and the oblique incisions of
Abernethy and M. Roux, present but one advantage — that of enabling the
operator to penetrate without much difficulty as high as he pleases — an ad-
vantage which is amply counterbalanced by the greater risk which he incurs
of wounding the peritoneum. The inferior or internal an^le of the wound
is the only point where it is possible to separate its lips, in order to search
for the vessel ; and it is perfectly useless to give a greater extent to the di-
vision of the abdominal parietes.
In the process of Sir A. Cooper, modified by Norman and Bogros, as well
as in that upon which I have just commented, the incision, crossing the vessel
almost at a right angle, renders it impossible to miss it. True, it is ob-
jected that this method does not permit the operator to reach high up in the
pelvis, and tliat it renders him more liable to wound the epigastric artery.
But on the one point it is possible by its aid to proceed to the depth of
three inches, and if the aneurism rises higher, it is the primitive and not the
external iliac that the operator must endeavor to tie ; and on the other, since
the tissues are divided, lamina by lamina, and torn rather than cut from the
place where the operator reaches the deep aponeurosis, sometimes long
I
* OPERATIVE SURGERY. 91
before, I cannot see how it is possible, unless by design, to wound the epi-
gasiitric which lies behind. Experience has proved that it is possible to use
successfully any of the methods which have been above described, and I am
perfectly aware that the question as to which is the best, is more a matter of
choice than of necessity, except that the transverse incision, which is always
sufficient when the tumor does not extend above the crural ligament, may
not be so convenient when the disease has reached a higher point. It is,
however, for the skillful surgeon to adopt those means which seem most appli-
cable to the cases which may come under his hands.
The blood is conveyed into the inferior extremity after the ligature in the
iliac artery, in the same manner as after the ligature of the femoral above the
profunda — by the gluteal, the ischiatic, the pudic, the obturator, and further
by the epigastric and the circumflexa ilii, by means of their anastomoses,
with the internal mammary, the lumbar, and the ilio lumbalis. The prox-
imity of the urinary and seminal passages, of the peritoneum and of the lax
cellular tissue of the iliac or lumbar region, demands all the attention of
the practitioner, and prompt relief when the slightest accidents occur from
that quarter. For the rest, such symptoms are to be treated by the means
generally known.
/. Internal Iliac.
Art. 1. — Anatomical Remarks.
The internal iliac, leaving the primitive iliac on a level with the sacro-
iliac symphysis, separates from the external iliac, and descends almost per-
pendicularly into the hollow of the pelvis. Its external surface is crossed
at its origin by the iliac vein, and accompanied in the rest of its extent by
the hypogastric vein, which separates it from the psoas muscle and the arti-
culation. On the inside it is united to the peritoneum only by a cellulo-adi-
pose stratum, varying in thickness; some lymphatic ganglions also rest
against it on the same side. The urethra commonly passes above and a little
more in front ; to the left, the commencement of the rectum covers it, but at
a greater distance; on the left its relations to the coecum scarcely deserve
attention. It is not possible to reach it, except in the part between its origin
and that of the gluteal, an extent of from one to two inches — -in a word, as
far as the level of the great sciatic notch. The ilio-lumbalis, which it some-
times gives off in its passage, and which then immediately proceeds outward
and upwards between the psoas muscle and the bones, should also be noticed,
altliough the primitive iliac artery or the external, more frequently give it off.
Art. %-^Surgical and Historical Remarks.
The trunk of the hypogastric artery is too deeply situated to be frequently
the seat of traumatic lesions, and is too short to be susceptible of relief in
any aneurisms which may affect it. Sandifort is the only one who has ever
reported a case of aneurism of this artery ; but it is not so with its principal
branches. After leaving the pelvis they are still sufficiently voluminous to
become the source of dangerous hemorrhage in the event of their being
wounded or experiencing spontaneous rupture; the gluteal artery particu-
larly, which is distributed to the muscles of the same name, and which cannot,
like the ischiatic or the pudic, be easily taken up from without, has several
times produced death in this way. Thedan reports an instance. In dilating
92 NEW ELEMENTS OF *
a gun-shot wound, a surgeon divided the gluteal artery, and tlie unhappy
soldier very soon expired. The same occurred in a case of aneurism, on the
patient mentioned by Jeffreys, of Glasgow. J. Bell, it is true, was more for-
tunate ; he saved the life of his patient by tying the v/ounded vessel. Mr.
Rogers has since made known an analogous case 5 and, in 1817, Mr. Brooke
cured, or believed that he had cured, a gluteal aneurism by compression, di-
gitalis, and laxatives. Yet it cannot be disputed that ligature ot the internal
iliac is the only method which can be counted upon for relief in most cases
of this kind.
Art.. 3., — Manual,
This operation was performed for the first time by Mr. Stevens, upon a
negress, who had in the left buttock an aneurism as large as the head of
an infant. The woman was completely cured, and lived some years after-
wards to die of another disease. Dr. Stevens, professor of surgery in New
York, informed me that he had seen the pathological preparation, fully bearing
out the assertions of the surgeon at Santa Cruz. On the 12th of May, 1817,
Mr. Atkinson, of York, followed the example of Mr. Stevens, upon a boatman^
who was in the same situation as the negress Maila : several hemorrhages
and an abundant suppuration brought on death at the expiration of twenty
days. Since then, Dr. Pomeroy White, of Hudson, in America, has been
more successful. He operated upon a tailor sixty years of age. A great
deal of pus issued from the parts during a month, but the health of. the
patient was eventually re-established.
Processes. — 1. Mr. Stevens at first divided the integuments, the aponeu-
rosis, and the muscles, to the extent of five inches, a little without, and in
the direction of the epigastric artery ; then, having detached the peritoneum,
pushing it towards the axis of the body from the spine of the ileum and the
division of the primitive iliac artery, he isolated the hypogastric trunk with
the fore-finger, and applied the ligature half an inch below its origin.
2. Mr. Atkinson followed the same method; but a profuse hemorrhage
obliged him to thrust the whole of his fingers into the iliac fossa, in order to
reach and tie the artery.
3. Dr. Pomeroy White njade an incision upon the side of the abdomen, in
the form of a half moon and about seven inches in length, the convex part
turned towards the ileum. This incision commenced near the umbilicus, and
terminated near the inguinal ring. After having thus divided the whole thick-
ness of the abdominal walls, tied several arteries, and detached the perito-
neum, he raised the hypogastric trunk with the handle of his scalpel, and
tied it an inch below the point of its origin, using afterwards sutures and
adhesive plasters to close the external wound.
As this operation is performed upon healthy parts far from the seat of tlie
disease, it is easy to practise it upon a dead subj<ict, and to becon>,e assured
that an incision of five inches, as made by Mr. Stevens, is sufficient, and is
even preferable to that recommended by Dr. White, because it enables the
operator to avoid all the branches of the epigastric without risk of wounding
the anterior iliac.
4. Another Method. — The operation may be performed, I think, with equal
success, by prolonging about two inches the external extremity of the inci
sion recommended by Sir A. Cooper for the ligature of the external iliac.
This mode of procedure was preferred by Dr. Anderson, of New York, " in
order," says he, *' more easily to preserve tlie peritoneum, and to prevent tlie
OPERATIVE SURGERY. 93
consecutive hernia, which occurred to a patient under the care of Mr. Kirbj,
as well as on the negress of Mr. Stevens." The incision advised by Aber-
nethy, is as eligible on this score as any other; whatever method, however,
may be adopted, great care must be taken not to scrape the peritoneum, or
lay it too bare of cellular tissue, in separating it with the fore-finger from
the parts to which it is attached. Having reached the internal edge of the
psoas, the finger is also used in separating the artery from the large veins
which partly hide it. The root of this trunk, like that of the external iliac,
is to be bent downwards and towards the centre of the pelvis ; then, aided
by the needle of Deschamps, the double curved needle of M. Causse, or a
flexible probe with an eye at its beak, the operator passes the ligature. The
greatest caution is here necessary ; the venous trunks should be carefully
avoided ; their sides are thin ; nothing is more easy than to injure them. In
displacing the artery also, there is a possibility of wounding the ilio-lumbalis
and producing a dangerous effusion of blood.
Result of the Operation. — The ligature of this artery, although it may at
the first view excite apprehensions in the mind of the operator, is in reality
less serious as to its effect upon the circulation, than that of the external iliac
or even the femoral. It in fact leaves untouched all the vessels proper to
the corresponding member, and the two hypogastric arteries communicate by
means of anastomoses so large and numerous, that after the obliteration of
the one the blood easily finds its way by the other into the viscera, which
they nourish. But it is dangerous in other respects j at first from the diffi-
culties attending its execution, and afterwards from the separation which it is
necessary to make in an abundant cellular tissue, and from which inflamma-
tion and suppuration are so easily propagated to a great extent.
K. Primitive Uiac.
Art. 1. — Anatomical Remarks.
Two causes effect a variation in the length of the common iliac 5 first, the
aorta often divides upon the body of the fourth lumbar vertebra instead of
the fifth ; secondly, the root of the secondary iliacs may be found nearer than
ordinary to the sacro-vertebral angle. One may also be sometimes found
larger than the other, because the trunk from which they originate does not
always lie upon the median line ; still, with some few exceptions, their length
scarcely ever varies more than from three or four lines to an inch. They
rest upon the side of the sacro-vertebral anglfr, upon the wings of the sacrum,
and against the internal face of the psoas muscles. On the right, the vein
is first in the outside, and then behind ; on the left, on the contrary, it lies
all the way on the inside, and does not reach the artery until afteV having
previously passed under the root of the arterial trunk of the opposite side ;
these vessels are covered only by the peritoneum, so that in attenuated subjects
it is still more easy to compress them than the external iliacs, provided
always that the operator has previously removed the mass of the small
intestines.
Art. 2. — Surgical and Historical Remarks.
Bogros opened the body of a patient who had been wounded in the primi-
tive iliac by a pistol ball thirty-six hours before death. Dr. Gibson, of Bal-
timore, reports a case precisely similar; we may easily conceive that aneu-
94 NEW ELEMENTS OF
risms may prolong themselves from the two secondary iliacs to the common
iliac, and even invade it primarily.
It needed more than common hardihood to undertake the obliteration of
an arterial trunk so voluminous, so near to the aorta, and so deeply situated*
In default of the external iliac the blood passes into the limb by the internal
iliac ; in default of one hypogastric, that fluid is furnished by the other ; but
what can supply the place of the common iliac ? Who can deprive a fifth of
the body of its circulation without producing death ? many surgeons still
believe it to be impossible. Yet Mr. Goodison, in 1818, remarked upon the
body of an old woman which he dissected at La Pitie, the complete oblite-
ration of the two primitive iliacs, without the lower extremities appearing in
any way to have suffered. The experiments also upon dogs, made by A.
Cooper and Beclard, together with those of Scarpa, had already solved the
problem. Were these facts sufficiently numerous and conclusive to warrant
actual application upon the person of a living subject? Practice has replied
in the affirmative ; and if refrigerants, a weakening regimen, laxatives, and digi-
talis have failed; if the aneurism rises so high as to render the ligature of
the external iliac uncertain and insufficient, and to prevent or render useless
the method of Brasdor ; if ther.e is, in fact, no other resource, the ligature of
the primitive iliac ought to be practised.
Mr. Gibson, it is true, tried it unsuccessfully in the case above mentioned ;
but Professor V. Mott, who practised it for the first time according to fixed
rules, on the 15th March, 1827, for an aneurism of considerable extent, saved
the life of his patient. The year following, Mr. Crampton, in endeavoring
to imitate the skillful practitioner of New York, was not so fortunate ; his pa-
tient died of hemorrhage on the fourth day. This latter case, is nevertheless
extremely important; the circulation, the warmth, and the sensibility, for a time
suspended, were afterwards completely renewed in the limb ; every thing
announced complete success, when the ligature seemed to displace itself, and
symptoms of internal hemorrhage disappointed these flattering hopes. On
opening the body every thinff tended to confirm the belief that the cord of
animal matter, employed by Mr. Crampton, had been dissolved or broke be-
fore the artery was obliterated. The authenticity of the last two mentioned
operations is sufficiently guaranteed by the names of the operators ; the one
enjoys a justly merited estimation and celebrity in America and throughout
Europe, and the other is at the head of a public establishment — a hospital in
England.
Art, 3. — Manual,
The mode of procedure to be followed is exactl^r the same as for the liga-
ture of the internal iliac. Dr. Mott commenced his incision on the outside
of the inguinal ring, half an inch above the ligament of Poupart, and carried
it above the superior spinous process of the ileum, giving to it a semicircular
direction and an extent of about eight inches. The incision of Mr. Crampton
was also in a semicircular form, the concavity towards the umbilicus and
about seven inches in length. It extended from the last rib to the superior
and anterior part of the crest of the ileum. Both operators detached the
peritoneum with the fingers; and there is no circumstance which tends
to prove that they experienced any difficulty in reaching or in tying the
vessel.
Here the circulation of the fluids is re-established by the anastomoses of
the internal mammary and of the epigastric of the last lumbar and circumflexa
' OPERATIVE SURGERY. 95
ilii or the ilio lumbalis, and then by the branches of the h3rpogastric of the
healthy side with those of the side affected.
L. Abdominal Aorta.
Art. 1. — Anatomical Remarks.
The abdominal aorta is placed upon the front and a little to the left of the
bodies of the vertebrae, accompanied by the vena cava on the right ; enveloped
by a fibro-cellular sheath ; crossed behind by the lumbar veins ; in front
by the pancreas, the duodenum, the splenic vein or the trunk of the vena-
portae, and the left venal ; and surrounded by vessels and lymphatic ganglions.
It has in front, the stomach, the transverse meso-colon, and the root of the
mesentery ; and from its passage between the pillars of the diaphragm to its
bifurcation above the sacro-vertebral angle, furnishes a great number of branches
worthy of notice. The coeliac, the emulgent, and the great mesenteric, derive
their origin from its superior half, that is to say, they originate above or in the
meso-colic portion of the mesentery. A great interval consequently separates
them from the inferior mesenteric, which is given off at an inch and a half or
two inches above the common iliacs. In crossing the body of the vertebrae,
the lumbar arteries pass under small fibrous arches, extremely firm, and thus,
like fixed roots, prevent the displacement of the aorta in either direction more
than a few lines, unless they are themselves previously broken.
From what has been said it is plain that by pushing to the right the small
intestines, or removing them in any way, it will be easy to compress the aorta
against the vertebrae, either between the two mesenteries or immediately above
its bifurcation ; that these are the only points at which it is accessible to the
surgeon, and that over one or the other of these the thumb should be applied
so as to act through the abdominal parietes when it becomes necessary to sus-
pend a serious hemorrhage of the inferior arterial system.
Art. 2. — Historical and Surgical Remarks.
No artery of the splanchnic cavities is more frequently the seat of aneu-
risms from internal causes, than the abdominal aorta; and no where does aneu-
rism or the slightest traumatic lesion occasion greater danger, or is it more con-
stantly followed by death. If it be true, and it is scarcely possible at the present
day to doubt it, that obliteration of the affected vessel is required for the cure of
any wound, ulceration, or solution of the continuity in its coats, how is it
possible to conceive that such a state, supposing it possible in the aorta, could
be induced there without fatal consequences ? The following facts, however,
prove that even this artery may be obliterated without causing death :—
1st. Stenzel states that he found two steatomatous tumors in the very
thickness of the sides of the aorta below its arch. The arterial trunk was
almost impermeable to the blood, and yet nothing during life had indicated the
existence of such a disposition of parts.
2d and 3d. In two bodies, the inferior extremities of which were well
supplied with blood, Meckel found the aorta considerably contracted below
its arch,
4th. M. A. Severin speaks of a subject in which the aorta was completely
closed below the emulgent arteries by a solid concretion.
5th. Staerk cites a case similar to those of Meckel.
6th. Paris saw the aorta so much contracted for several lines' below the
96 NEW ELEMENTS OF
arch, that he had great difficulty in introducing a crow-quill into the passage %
Brasdor saw this preparation in the cabinet of Desault.
7th. An instance of complete obliteration at the same point of the parent
artery, is related by Graham in the Medico-Chirurgica' Transactions.
8th. Mr. Rainy states that he observed a similar case at the Glasgow Hos-
pital in 1814, and that he presented the preparation to Mr. Monteith. May
not this be the case alluded to by Mr. Graham ?
9th. Doctor Monro mentions an example of the aorta obliterated imme-
diately above the primitive iliacs, by the remains of an old aneurism.
lOtn. A similar case came under the observation of Mr. Goodisson, in which
the obliteration had extended to the two common iliacs.
11th. M. Reynaud has recently made known an additional case of extreme
contraction of the thoracic aorta.
Lastly. A peasant, thirty-three years of age, died suddenly in the begin-
ning of February 1828, after having suifered during fifteen or twenty days
from a painful gastric affection. On opening the body, M. A. Meckel disco-
vered that the death of the patient had proceeded from an injury of the auricle
of the heart, and afterwards perceived that the aorta was so contracted as
scarcely to allow the passage of a straw. Mr. Crampton, of Dublin, also
mentions a case of complete obliteration of the abdominal aorta. Sir A. Cooper
says that his attention was directed to another case of this kind, and that a
similar one was also witnessed by M. Larrey. Mr. Key also, has recently
published another example in the case of a paraplegiac.
In nearly all the above cases, the state of the aorta was evidently the re-
sult of disease, and in all, the circulation continued below the interception.
The patients spoken of by Messrs. Rainy and Key, were the only ones who
complained of habitual feebleness in the legs or of paralysis. Messrs. A,
Cooper and Beclard, in their experiments upon dogs, are said several time*
to have tied the ventral aorta without producing gangrene. In 1813^ I dis-
sected a cat, upon which M. Pinel Grandechamp had four months before
practised this operation. The animal had perfectly recovered, and the ab-
dominal aorta was transformed into a fibro-cellulous filament, from the supe-
rior mesenteric to the origin of the primitive iliacs. M. Scoutetten obliterated
successively the two femorals, the two carotids, and the two subclavians of a
dog, and afterwards tied the aorta'without producing death. The animal lived
six days, although an intense j9er27owi7is developed itself the morning after
the operation, wlien a laceration of the aorta took place above the ligature on
the seventh day, and caused the animal to die suddenly.
If the above facts do not authorize the conclusion that ligature of the vea-
tral aorta may without temerity be practised upon a human subject, they
prove at least and most incontestably, that the blood would find some other
way to reach the inferior members. The intercostals and the superior lum-
bars, the internal and external mammaries, the transverse and posterior cer-
vicals, are sufficiently voluminous, in fact, to convey the fluids to the parts
below the ligature. By examining the engraving which accompanies the ob-
servations of M. Reynaud, together with what has been said of it by Graham,
Paris, Al. Meckel, &.C., the reader will immediately comprehend the great re-
sources possessed by the system in these cases. Moreover, if the thread is
placed between the two mesenteries, instead of below them, large arches v/ill
be formed by the meeting of the right and left colic branches. The human
body is in reality but a vast net-work — a great vascular circle — and no one
need now fear that the course of the fluids can be arrested by the obliteration
of any one of its points.
OPERATIVE SURGERY. 97*
Let us now consider whether tlie ligature of the aorta is useful and practi-
cable. Practicable it certainly is, for Messrs. Cooper and James have per-
formed it, but its utility has not been yet so conclusively demonstrated. For
aneurism of one or both common iliacs, and for those which develop them-
selves above the superior mesenteric, there appears to be no other resort —
and the observations of Messrs. Monro and Goodisson, the case of spontaneous
cure of an aneurism of the aortic arch, published by Dr. W. Darrah, of Phila-
delphia, and a similar case mentioned by M. Calmeil, prove the power of the
organization under circumstances like these. Internal treatment, cold to-
pical applications, moxas, the cor. .ned methods of Valsalva, of Guerin and
of M. Larrey — do not these means offer greater chances of success than all
the operations that could be continued ? Time and the experience of able
practitioners will eventually solve this grave problem; in the mean time, as
it may become necessary to imitate the attempt of the English surgeon, I shall
give the rules for the operation.
Art. 3. — Manual
I do not see any merit in the idea of penetrating the left side, so as to"
reach the aorta without opening the peritoneum ; on the contrary, I am of
opinion that such a method oun:;ht never to be resorted to. If it is doubtful
whether it might not be applied in nephrotomy, or in forming an artificial
anus, it is certain that, for ligature of the aorta, it ought not even to be
thought of. The only method which can be prudently attempted is the fol-
lowing : —
The patient should lie upon his back, with the head, the thighs, and the legs
moderately flexed, so as to place the parietes of the abdomen in a state of per-
fect relaxation. An incision three or four inches in length is then made upon
the linea alba, a little to the left, in order to avoid the umbilicus — above which
I think it will be found convenient to extend it a little farther than below.
Having arrived at the peritoneum, the operator pierces it to divide it more
extensively with a probe-pointed bistoury conducted upon the finger; by this
opening the fore-finger removes the intestines, penetrates to the vertebral co-
lumn, distinguishes the pulsations of the artery, separates with the nail the
left lamina of the mesentery and the subjacent cellular sheath, and removes
gently the p.orta from the vena cava and from the body, or rather the cartilage
of a vertebra, so as suitably to isolate it. If the patient is of a meagre habit,
if the walls of the abdomen are very near the vertebral column, if the eye in
short can follow the instruments to this place, a sound may, in this stage of
the operation, be advantageously substituted for the finger. The ligature is
passed by means of the needle of Deschamps, or by the ordinary method, and
tied with a double knot ; one end is cut near the artery, and the other is suf-
fered to remain in the wound, which should be closed with a few stitches,
and strips of adhesive plaster. If the ligatures of animal substance, proposed
by Messrs. Physick, Lawrence, Jameson, &c., offered the same security as
others, they ought in this case to be preferred, leaving the knot in the depths
of the parts ; experience, however, not having yet pronounced upon the merits
of this kind of ligature, I do not venture at present to recommend them.
In the case of the patient operated upon, ^th June 1817, at nine o'clock
in the evening, who died on the 27th, at eighteen minutes past one, Sir A.
Cooper placed his ligature three quarters of an inch from the primitive iliacs.
It would probably have been better to carry it above theJnferior mesenteric
jytery, for reasons which must be obvious to every one. Before tying the
13
98
NEW ELEMENTS OF
aorta, at the Exeter hospital, on the 5th July, 1829, Mr. James had attempted
on the 2d of the previous month to obliterate the external iliac by the method
of Brasdor, without any decided advantage. His patient died in a few hours.
On opening the body it was found that the iliac artery was divided into two
trunks, which fact shows why the first operation, which was followed by a
diminution in the pulsations of the tumor, did not prevent them from regain-
ing their original force a short time afterwards. The process of Mr. James
was very similar to that of Sir A. Cooper.
SECTION II.
ARTERIES OF THE SUPERIOR EXTREMITY.
A. Arteries of the Hand.
Art, 1. — Anatomical Remarks.
The deep palmar arch, extended in the form of the segment of a circle
convex towards the fingers, from the beginning of the first interosseous space
to the hypothenar eminence, where it is completed by the termination of the
ulnar, imbedded between the muscles and the bones of the metacarpus behind,
and the flexors of the fingers or other soft parts of the palm of the hand in
front, is so deeply situated as to render useless any farther study of it with
reference to aneurism. The ulnar, or superficial arch, represents with toler-
able exactness the direction of a curve of about fifteen lines in depth, the
extremities of which fall upon the prominences of the pisiforme and the tra-
perzium. It is covered at its origin by some fibres of the muscles of the little
finger, in the middle by the palmar aponeurosis, and by the subcutaneous
substratum through its whole extent ; and furnishes, from its convexity, the
lateral arteries of almost all the fingers. The branches of the median nerve,
the tendons of the superficial and deep seated flexors, the lumbricales, and a
very loose synovial membrane, separate it from the deeper arch, with which
the anterior branch of the radial artery, a collateral of the thumb, and the
deep branch of the cubital, open to a free communication.
Art, 2. — Surgical Remarks,
We often meet in the hand with wounds of the arteries, capable of becom-
ing dangerous by hemorrhage. The hand is sometimes also, though rarely,
subject to circumscribed aneurism. Guattani met with one as large as an
orange in front of the thenar eminence. Becket, and F. de Hilden also
mention each a similar example. If compression have proved insufficient to
suspend the hemorrhage, or discuss the aneurism, the operator may, if the
extremities of the wounded artery are perceptible at the bottom of the wound,
imitate the practice of M. Roux, in seizing and tying them. The difficulties,
however, experienced by M. Roux himselt m a second operation, and by M.
Manoury in another, together with the dangers of all kinds which attend in-
cisions in the palm of the hand, are enough to prove that it would be preferable
to apply the ligature upon the radial, or upon the cubital, above the wrist.
Art, S. — Manual,
Nevertheless, the operator will find no difficulty in reaching the super-
OPERATIVE SURGERY. 9!^
ficial palmar arch, near its root, by beginning an incision upon the side of
the OS pisiforme, and prolonging it for about an inch forwards, and in the
direction of the last metacarpal space. He will have to divide successively
the skin and its cellulo-filamentous lining, a thin aponeurosis, and several
fleshy fibres.
It would also be equally easj to tie the origin of the deep arch upon the
back of the hand ; the extremity of the radial is there at the bottom of the
groove which separates the proximal extremity of the first two metacarpal
bones. A fibrous lamella separates it from the tendons of the thumb, from
the cephalic vein, and from the skin. The thumb and the index finger should
be extended and forcibly held apart, so that the surgeon may not be hindered
by the dorsal tendons of those two fingers. An oblique incision, about an
inch and a half in length, is made at three lines from the cubital side of the
long extensor of the thumb, and in the direction of that tendon. Beneath
the skin may be perceived one of the great metacarpal veins, and one of the
branches of the radial nerve. If pushing them aside is not found sufficient,
they must be cut. The artery is still concealed bv the aponeurosis, which
ought not to be divided except upon a director. Finally, in isolating the
vessel with the beak of the director, the operator must be careful not to lose
sight of the vicinity of the carpo-metacarpal articulation.
JB. Arteries of the Fore-arm.
Art. 1. — Anatomical Remarks,
In the fore-arm, the posterior interosseal artery, distributed between the
two corresponding muscular layers and the anterior interosseal, accompa-
nied by its nerve and resting upon the ligament of the same name, are both
of them too small, and too deeply situated, to receive any assistance from
the ligature. The radial and the cubital, then, are the only arteries to which
the attention of the surgeon should be directed.
1st. In its inferior third, the radial artery runs in the groove which sepa-
rates the tendons of the flexor radialis and the supinator longus, and is
covered only by a single aponeurotic lamina, the subcutaneous stratum, and the
skin ; one or two veins accompany it, the nerve is some lines to the outside,
and it lies almost immediately upon the anterior face of the radius. Its re-
lations are also somewhat complicated. It rests upon the pronator teres or
the radial portion of the flexor sublimis, upon which it is fixed by a fibrous
lamina, and is covered by the internal edge of the supinator longus. It is
also separated from the integuments here as well as below, by the brachial
fascia and the superficial cellular lamina. Throughout its whole extent, its
passage is represented by a line^ drawn from the middle of the elbow to the
base of the styloid process, or by the outermost groove on the front of the
fore-arm. It sometimes runs immediately under the skin; but more fre-
quently it runs down upon the external surface of the radius, from the
middle of its length; while in other cases its principal branch remains in
front and forms almost alone the superficial palmar arch.
2d. The ulnar, covered in the upper part of its length by the whole
thickness of the superficial muscular stratum, is on that account accessible to
the surgeon only in the three inferior fourths of its extent, where it is found
upon tlie flexor profundus, between the flexor sublimis and the flexor carpi
ulnaris. The vein is on the outside and the nerve on the inside ; that is, on the
ulnar side ; first an aponeurosis, then tlie flexor ulnaris muscle or its tendon,
100 NEW ELEMENTS OF
and lastly a second fibrous lamina and the adipose stratum, separate it from
tlie skin. Its direction in its two inferior thirds is traced by means of a line
extending from the internal condyle of the humorus to the radial side of the
pisiforme ; and in its upper third, from the middle of the elbow to the
junction of the middle with the superior third of the ulna. Its anomalies of
position are much more frequent than those of the radial ; I have often found
it between the aponeurosis and the skin, sometimes in the whole and some-
times only in part of its length, and am acquainted with several individuals in
whose persons it is thus placed. At other times it is found between the apo-
neurosis and the muscles ; and in certain cases it remains for a considerable
time near the axis of the limb, only approaching the ulnar nerve near the
wrist.
Art. 2. — Surgical and Historical Remarks.
Aneurisms of the radial, near the wrist, may doubtless yield to compres-
sion : Tulpius cites an example ; and this means certainly should be tried,
as has been remarked by M. Roux, with patients who are irritable or timid;
like him mentioned by Petit, of Lyons, who died of Convulsions in conse-
quence of the ligature of the radial. Doubtless, also, the greater number of
hemorrhages of the hand and fore-arm may be arrested by a well-applied com-
pression. This, however, does not invalidate the assertion that ligature is
the surest and least dangerous remedy in all injuries or diseases of this nature-
These are two means which it is often found advantageous to combine. For
example, instead of ty in^ at the same time both arteries of the fore-arm for
a wound in the hand, wliich would seem to be required by the free commu-
nication established by the two palmar arches, it is sufficient to apply a ligature
upon the principal trunk, and to compress the other. At the wrist, or above,
if the superior extremity of the open artery is tied, it will be sufficient to
compress the inferior extremity to prevent hemorrhage from the return of the
blood. These directions apply also to circumscribed aneurisms. If the affec-
tion, whether traumatic or spontaneous, occurs on the dorsal branch of the ulnar
artery (of which Messrs. Petit and Baretta observed an example in the hos-
pital at Lyons), or on any other branch of the same region, the ligature, which
is almost perfectly safe and easy to apply, ought to be preferred to all other
means, and should be placed both above and below the disease. Unless the
ligature is applied within the wound itself, it should be placed immediately
above the wrist, or else in the superior third of the fore-arm.
Art. 3. — Manual.
1st. The Radial above the Wrist. — When the radial artery is to be tied
above the wrist, the hand should be held supine, the surgeon then, standing
on the cubital side, makes with a straight or convex bistoury an incision of
the integuments one or two inches in extent, over the course of the artery,
taking care not to proceed too deeply at first. He afterwards divides the
aponeurosis upon a grooved director, so as to avoid touching the vessels
M'ith the bistoury. As the nerve is at a considerable distance, and the col-
lateral vein is almost unimportant, it is indifferent whether the artery is
raised from its internal or external side, but the operator should avoid de-
taching it too extensively.
2d. Ulnar above the Wrist. — The hand and the fore part of the arm are
placed, as for the radial in a supine posture; the incision is also of the same
extent and in the same direction. It is not necessary that it should descend
OPERATIVE SURGERY. 101
to the level of the radio-carpal articulation ; and it should be made upon the
radial edge of the iiexor ulnaris muscle, or in the groove in the front of the
fore-arm which lies nearest the ulnar edge. After having divided the skin,
the adipose stratum, and the thin fibrous lamina which covers the tendon of
the flexor ulnaris, and pushed that tendon outwards, the artery will be per-
ceived through a second aponeurotic lamina, a little before and to the radial
side of the ulnar nerv'e.
3d. Radial in the superior third of the Fore-arm. — As it is necessary to
penetrate more deeply in the superior lialf of the fore-arm than into the infe-
rior half, the incision must be at least two inches in length, and should be a
little oblique from within outwards, so that it may not fail to pass over the
line of direction of the artery. If the superficial radial vein, or the common
median vein presents itself under the skin, it must be pushed aside with the
director. It is better to fall some lines on the outside than on the inside of
the edge of the supinator longus muscle. In the former direction the aponeu-
rosis is not yet double, but presents only a single lamina, while in the other,
that is to say, over the edge of the muscle, a primary lamina must first be
divided, and the fleshy fisciculus drawn somewhat outwardj a second lamina
appears beneath which is cut upon the director, and the artery may then be
easilv taken up.
4tt\. Ulnar in the superior third of the Fore-arm. — Ligature of the cubital
towards its superior third, is counted one of the most difficult operations per-
formed upon the upper extremity. This impression doubtless proceeds from
the fact, that the greater part of authors have given only vague and indefinite
rules for its execution. I have never found that, when performed in the fol-
lowing manner the operation required greater skill than the ligature of the
radial: an incision is made three or four inches in length, beginning at three
fingers' breadtli from the trochlea of the humerus and descending to the
middle of the fore-arm, in the line above described. The aponeurosis being
laid bare, the interstice betw^een the flexor ulnaris and the flexor of the little
finger is next sought for. To prevent the possibility of error, it is only neces-
sary to draw the internal edge of the wound towards the cubital side of the
member ; and in returning afterwards towards the median line, the first yellow
or greyish trace indicates positively the interstice required. An incision
is then made in the aponeurosis upon the external edge of this line, of the
same extent with that in the skin; this done, the flexor ulnaris and the flexor
minimi digiti are separated from each other by means of the index finger, the
handle of a scalpel, or a director; the operator will then see at the bottom
of the wound a large yellow or whitish cord, which is the cubital nerve, having
the artery on its radial side.. In taking up the latter it is not even necessary
to see it. It may be safely and surely raised by passing the beak of the sound
between it and the nerve. If the disease occupies a more elevated point of
the cubital artery, since that vessel changes its direction and becomes more
and more difficult to discover, it will evidently he preferable to tie the brachial.
C. Arteries of the Elbow.
Art. 1. — Anatomical Remarks.
At the bend of the arm the humeral artery usua'lr divides into the radial
and ulnar branches ; but instead of being always opposite or below the coro-
noid process, its bifurcation occasionally takes place in front of the articulation.
102 NEW ELEMENTS OF
and sometimes even still higher. In descending it takes an oblique direction
from within outwards, lies upon the inner portion of the brachialis anticus
muscle between the biceps and the pronator teres, and lower down tends to
cross in the same direction the anterior surface of the tendon of the biceps. The
deep vein runs along its radial side, and the median nerve, which sometimes
touches its cubital edge, is frequently separated from it by a fasciculus of the
brachialis anticus muscle. A cellular sheath, more or less dense, envelopes
it with the vein. It is crossed and confined by the anterior tendon of the
biceps, and is farther covered by the aponeurosis of that region. It has in
front, first, the trunk of the basilic vein, then the corresponding median
vein, the branches of the internal cutaneous nerve, and the cellular adipose
stratum, which remove it more or less from contact with the skin. When its
division takes place higher than usual, the nerve generally lies between the
two arterial trunks^ in which case particularly the cubital is disposed to come
forward under the skin.
Art. 2. — Surgical and Historical Remarks.
The bend of the arm is more subject to aneurism than any other part of the
body, particularly to false and traumatic aneurisms, whether diffuse, circum-
scribed, or varicose. Spontaneous aneurism takes place here, as in front of all
the great articulations, in consequence of violent extension as in case of the
carter mentioned by Saviard. It is much more rare, however, in this part than
at the ham, or even at the bend of the groin. Besides the cases reported by
Fordyce, Flajani, Paletta, Lassus, Pelletan, p,nd Roux, we can scarcely find an
example of the kind in the most esteemed authors. Scarpa himself does not
seem to have met with one. The bend of the arm is the favorite seat of vari-
cose aneurism, whether simple, false, or circumscribed. I have also seen a
varicose dilatation, a true hypertrophia of all the arteries of the hand and fore-
arm, extending to the height of the tendon of the biceps. Formerly, when minor
surgery was in the hands of barbers and persons without any notion of ana-
tomy, it was thought that in performing the operation of phlebotomy the artery
must of course be frequently wounded. Now, however, tliat this brancji of
the art is confided exclusively to young surgeons or medical students, this
accident is far more rare than formerly.
To understand the different forms and various directions taken by aneu-
risms of the elbow, it is necessary to give the most serious attention to the
situation of the aponeurosis. If the puncture take place under the super-
ficial tendon of the biceps, the aneurismal tumor finding here an opening
somewhat similar to that in the fascia lata in the inguinal region, will be able
to develop itself with great rapidity in an equable manner, and may cor-
respond by its centre to the perforation of the vessel. Above this barrier, the
fibres of the aponeurosis, which are separated by small intervals and not firmly
united, will at first for a time resist and mask the tumor, but eventually they
will give way, and its progress will from that time cease to be impeded. If,
on the contrary, the lesion is immediately behind the lamina in question, the
tumor to enlarge itself must deviate from a vertical direction; will more fre-
quently expand itself below than above, towards one of those points which
have been mentioned ; and will afterwards issue sometimes at a considerable
distance from the place of its origin. Ligature of the brachial artery in this
region is practised not only for aneurisms of the bend of the arm, but also for
those which occupy the superior third of the fore-arm. At the present day it is
even more frequently applied in the latter than in the former cases, since
OPERATIVE SURGERY. lOS
AneP6 method renders it necessary to carry the ligature upon a point more
or less elevated above the elbow.
Spontaneous cures of aneurisms of the bend of the arm, or cures assisted
by compression, have been so frequently seen as to have become quite a com-
mon affair. D. Pomaret, of Montpeliers, gives an account of a patient who
would not submit to an operation, and who was perfectly cured by the burst-
ing of the aneurism. Monte^gia speaks of a man aged seventy-seven years,
who had the artery opened m the operation of phlebotomy, and an attempt
made to close the wound with a bandage. The patient was not able to bear
this treatment. Several symptoms occurred to disquiet the surgeon, but they
soon vanished and with them the aneurismal tumor. Galen cured an aneu-
rism at tlie elbow of a young man by means of regulated compression.
Genga appears to have frequently succeeded by means of the bandage com-
monly ascribed to Theden, White", Desault, Foubert, Scarpa, and Stoker, and
quite recently the German journals have reported examples in favor of this
metliod. The Abbe Bourdelot caused it to be generally adopted more than
a century ago, by applying it with success upon his own person, for circum-
scribed aneurism at the elbow.
Again, the malady may proceed so slowly as scarcely to interfere with the
usual avocations of the patient. An aneurism of the bend of the arm, says
Saviard, *• happened to a man after the operation of phlebotomy; it was of the
size of a nut, and was carried by the patient for seventeen years, during the
whole of which time he pursued his ordinary labor in a coal mine. Suddenly,
however, the tumor increased to such a degree as to produce a considerable
swelling of the arm, and it was with great difficulty that gangrene of the
member was prevented." These aneurisms always sooner or later (with a
few rare exceptions) come to endanger the life of the patient ; the surgeon,
therefore in ordinary cases, should never suffer himself to be stopped or influ-
enced by the consideration of such cases as those above mentioned. If com-
pression does not appear to him to be sufficient, or is not attended with
marked amendment, it is his duty immediately to have recourse to the liga-
ture.
The methods of Aetius, of Paul of Egina, and of Guillemeau were only
applied to aneurism of the elbow, until Keisleyre, and the Italian surgeons
ventured to apply the same mode of treatment to aneurisms of the popliteal
space. And it is in this part that Anel cured an aneurismal tumor without
touching it, by simply tying the artery above the seat of the disease. Mirault,
of Angers, was the first amongst us who imitated him in this operation towards
the commencement of the present century. Although it is generally admitted
that the method of Anel is here sufficient, that of Keisleyre is still sometimes
practised ; in diffused aneurisms, for example, and in varicose or circum-
scribed aneurisms, when the sides have become extremely thin or much dis-
eased. The reason assigned in the first case is, that in limiting the operation
to ligature of the artery above the lesion, there is a possibility of a return of
hemorrliage from below^; in the second, that by the obliteration of the artery
above, the blood is not prevented from passing from the vein by the opening
of communication ; in the third, that by Anel's method it is impossible when
the disease has reached this stage to obtain resolution of the aneurismal sac,
which it is necessary to open and empty of coa^ula in order to prevent gan-
grene, and that in all, the method of Keisleyre -will preserve a greater number
of anastomic branches.
These motives do not, really in any way demonstrate the absolute neces-
sity of the ancient method in these cases. The application of a ligature above
104 , * NEW ELEMENTS OF IT'
the injury is always easy and simple, but through an opening in the sac or over
the place of the wound it is sometimes more laborious and difficult. If the
tumor do not contract after the operation, if it threatens to gangrene, or form
an abscess, there is nothing to prevent its being treated as a purulent collec-
tion. Compression, even moderately used, will rarely fail to arrest hemor-
rhage, supposing it should take place after the : pplication of a ligature above
^ recent traumatic aneurism. It is true that in the case of a patient operated
upon by the new method at the Hotel Dieu, by M. Breschet, the advance of
the aneurismal sac yielded only to the opening of the bag and the ligature of
both ends of the artery, but it is not certain, from the details of the operation,
that the humeral artery was embraced in the ligature at the time of the first
operation. But Mr. Guthrie, a declared partizan of Keisleyre's method, reports
a case which furnishes matter for reflection upon this point A man of good
constitution had the artery pricked with a lancet. It was tied above the
■wound. Hemorrhage re-appeared. It was tied still higher. A new incision
-was made. The member was amputated and the patient died. "It was
necessary," says Mr. G. " to tie, not only the brachial, but even the origin
of the radial and the ulnar." As to varicose aneurism, it rau^t be acknow-
ledged that a certain number of facts seem fully to justify exclusive resort to
the old method, as recommended by Messrs. Richerand and Dupuytren.
Four examples cited by M. D. in support of this opinion, may be found in
Sabatier's Operative Surgery. In the first case, notwithstanding the appli-
cation of the ligature by Anel's method, amputation of the member became
necessary. In the second, a false anchylosis of the fingers, and other unfor-
tunate results rendered amputation also necessary. Finally, in the third and
fourth, the patient underwent a second operation in which the surgeon tied
the artery above and below the wound.
Art, 3. — Manual.
When he has decided to tie the brachial artery at the elbow, the operator
proceeds as follows : — The fore-arm is extended upon the arm, more or less
removed from the trunk, and held supine. An incision is then made three
inches in length, parallel to the radial or superior edge of the pronator teres
muscle, commencing nearly an inch above the epitrocnlea, and terminating in
the middle of the bend of the arm. Beneath the skin are the superficial veins,
the median basilic vein, and the branches of the cutaneous nerve which
accompany it. These are held aside by an assistant with a blunt hook, or
the beak of a probe bent for the purpose. Whenever any of their branches
impede the operation, or cannot be conveniently displaced, they should be cut
between two ligatures, or even without that precaution when they are not too
voluminous. The aponeurosis is next seen, and must be divided upon the
4iirector, even when it would be possible to preserve the superficial tendon of
the biceps, it is better to sacrifice it : the remainder of the operation will thus
become much more easy, and a powerful cause of inflammatory strangulation
"will be destroyed. After having disembarrassed the artery from the lamellar
and adipose cellular tissue which surrounds it; after having separated it from
the deep vein or veins and from the median nerve, the operator passes be-
tween it and this latter cord the extremity of a probe, which he then causes to
glide behind it so as to raise it, whilst with a nail of the other hand he hinders
the veins from following it, or from lying under the point of the instrument.
After this the ligature is applied, and the operation is done.
The course of the blood for a time interrupted, quietly re-establishes itself
.^l OPERATIVE SURGERY. ,- 105
bj means of the two anastomic circles formed by the internal and external
collateral branches of the brachial round the epicondyle and the epitrochlea,
with the recurrent branches of the radial and the ulna. Thus it is not bj any
means necessary, in order to explain this phenomena (as it was for a long time
believed), that the artery of the elbow should be divided into two trunks above
the obliterated point.
B. The Brachial.
Art. 1. — Anatomical Remarks.
The humeral artery is situated in the middle of the internal bicipital chan-
nel. Its passage corresponds with an oblique line drawn from the hollow of
the arm-pit to the midd^e of the bend of the elbow. The median nerve, which
in the upper part of its course runs along the radial edge, afterwards covers
the cutaneous surface, which it crosses very obliquely to take low down a
position on its cubital side. Two venae comites usually attend it, sometimes
touching and even covering it, and separating it from the median nerve.
The ulnar and internal cutaneous nerves which are next it above, recede from
it more and more as they descend, so to reach the internal side of the fore-
arm. At first it lies against the humerus, between the ceraco-brachialis and
the tendon of the latissimus dorsi, but soon arrives upon the brachialis anticus
behind the biceps, wliich it accompanies to its termination. Upon attenu-
ated subjects, the aponeurosis is nearly in contact with it, and doubles itself
so as to envelope its trunk and that of its collateral vein, and furnishes a
sheath to the median nerve and other lamellse which unite these different
organs so as to form of all a sort of common mass. The whole is covered, as
elsewhere, by the common integuments ; in the inferior third by the trunk of
the basilic vein. Its anomalies are so frequent that every body knows them.
I have sometimes seen it divided into two trunks near the axillary cavity —
sometimes at some inches below— sometimes at the middle of the arm — some-
times just above the elbow — in fact, at all heights of the limb. In one sub-
ject, one of these branches divided at two inches from the epitrochlea, in
in order to form tl\e ulnar and the posterior interosseal. In another case, the
latter was given off independently of the radial and ulnar. The two trunks
sometimes remained side by side, as far as the fore arm.; at other times they
cross each other at one or more points. It is not at all extraordinary to see
one, generally the ulnar, piercing the aponeurosis and running immediately
under the skin ; whilst the other, which then furnishes the radial and inter-
osseal, preserves its customary relations.
Art, 2. — Surgical and Historical Remarks.,
The brachial artery may become the seat of aneurismal affections almost
indifferently, upon almost all points in its extent; it is however infinitely
more disjjosed to them at the bend of the arm than at any other part. As
nothing hinders their equable development, the tumors caused by these mala-
dies are ordinarily regular, speedily acquire considerable size, and fre-
quently lie with the centre over the opening of the artery.
Previously to having recourse to the ligature, it is sometimes admissible to
employ compression and refrigerants; the humerus here offers a reacting
surface, which is particularly favorable to the employment of these means.
14
106 ^ NEW ELEMENTS OF
M. Lisfranc mentions a patient who had four aneurisms upon the arm, the
progress of which he arrested for a whole year by means of a laced sleeve.
The Queen of Bavaria, and another personage of the north, were cured of
aneurisms of this kind by M. Winter, with a compressive bandage. But it is
upon the humeral artery that Anel's operation for aneurism is most commonly
performed. There the vessel is superficial, easy to be taken up, and sur-
rounded by healthy parts preserving their natural relations ; whilst in front of
the articulation, the tumor sometimes masks the seat of the perforation in
such a manner as to render it very difficult to discover. The application of
the ligature near the arm -pit or the elbow, provided the principal collateral
can be preserved, causes a disturbance in the circulation in both cases almost
the same. Nevertheless, as a grand rule, the ligature should be practised
at as low a point as the situation of the malady will permit. No case, except
a diffused aneurism or a still bleeding wound, appears to call for the old
method in preference to the new. If the aneurism is too high, the axillary
should be tied, unless it is judged better to adopt the method of Brasdor.
Art. 3. — Manual.
The member being placed as previously described, the operator seeks the
groove at the edge of the biceps, carries the bistoury in the direction of the
arterial line from above downwards for the right arm, and from below upwards
for the left, and makes an incision of two or three inches through the integu-
ments. Immediately afterwards he slips the left index finger into the wound,
and endeavors to feel the median nerve, \vhich presents a cord of consider-
able firmness and which may be distinguished from the artery by the pulsa-
tions of the latter ; he then divides, one after the other, upon a director, the
aponeurosis, and the sheath which it gives to the medio-digital nerve ; tears
always with the beak of the sound the cellulo fibrous sheath of the vessel,
separates the artery from the veins which accompany it, and passes the liga-
ture. This operation cannot become difficult except in consequence of some
anomaly or change in the relations of the organs. The median nerve is the
first cord which presents itself behind the biceps muscle ; I have only once
seen it under the artery, between that vessel and the brachialis anticus muscle.
Whenever it is recognized, the operator maybe sure that the vessels are not
far oft".
When the brachial is obliterated, the circulation continues below by means
of the numerous muscular branches which this trunk furnishes at different
points of its length, by the great collateral or external collateral, and by the
anastomica manrna, if this latter have not been sacrificed.
E. Axillary.
Art. 1. — Anatomical Remarks.
I shall call by the name of the axillaiy artery, only that portion of the
brachial trunk which extends from the clavicle to the origin of the humeral
artery. It may be considered in two points of view — from the hollow and
from the anterior face of the axilla. 1st. In tlie first direction it is only sepa-
rated from the skin by the two sorts of the median nerve, by that nerve itself,
by the axillary vein, a stratum of adipose filamentous cellular tissue, becom-
ing thicker as it approaches the apex of the axilla, by the aponeurosis, and bv a
second cellular stratum. The sorts of the thoracic and subscapular veins, kc.
> OPERATIVE SURGERY. * lOT
cross it and hide it at different points, whilst the other nerves of the brachial
plexus which first lie in front, soon pass behind it to gain the cubital side of
the arm. Outwardly, it rests upon the tendon of the subscapular muscle and
upon the humeral articulation upon the head and the neck of the humerus,
and between the tendon of the teres major behind and the pectoralis minor
or coraco brachialis in front. 2dly. In the other direction it is at a consi-
derable distance from the skin, and ought to be studied above and below the
pectoralis minor, which crosses it at two or three inches in front of the cla-
vicle, producing two triangular spaces, of which the superior, which I shall call
clavi-pectoraU limited below by the edge of the muscle, above by the clavicle,
and outwardly by the coracoid process, is the more remarkable. A fibro-
cellular lamina, sometimes quite dense, which I have named the coraco-clavi-
cular aponeurosis, covers its plane, and separates it from the pectoralis major.
Below is the vascular and nervous plexus. The vein is placed on the inside
towards the breast, and the anterior root of the median nerve on the outside
towards the shoulder, in such a manner that both partly cover the artery,
which lies between and a little behind them. This disposition is almost in-
variable, and greatly facilitates the operation. At the summit of the triangle,
the cephalic vein, together with those that come from the promontory of the
shoulder to empty into the axillary beneath the clavicle, are obliged to cross
its interior face. This is true also of one or two thoracic branches of the
nervous plexus. It there furnishes the acromial artery and the principal ex-
ternal thoracic, before passing under the pectoralis minor muscle.
The second triangle, which is bounded by the inferior edge of the lesser
pectoral muscle above, the superior fourth of the humerus on the outside,
and the anterior edge of the axilla below, is entirely covered by the pectoralis
major muscle. Here the median nerve is in front, the ulnar on the outside,
the radial or musculo-spiral behind the vein, on the inside of the artery ; in
fact, it is completely enveloped by these organs, to which it^is also united by
a cellulo-fibrous sheath of considerable strength. The subscapular and ex-
ternal thoracic veins and sometimes the basilic, come in to add to the complexity
of these numerous affinities. The lymphatic ganglions are thrown back much
more towards the breast, and thus, in addition to the cellular tissue, remove it
from the external surface of the serratus ma^nus. Finally, an adipose stratum,
of greater or less thickness, the pectoralis major, a lamella rather cellular
than fibrous, the subcutaneous tissue, and the skin, cover all these various
objects.
Art. 2, — Surgical and Historical Remarks.
Aneurisms and wounds of the axillary artery demand the most serious atten-
tion. Although they are less frequent here than at the ham, at the groin, or
at the bend of the arm, they are more so than upon any of the other part of
the body. This fact is easily accounted for by the position and volume of the
vessel, its relations to the articulation, and its proximity to the heart. It is
subject to every species of aneurism ; even varicose aneurism has been ob-
served in the axillary by Larrey, of Toulouse, and by M. Boisseau. The
pressure which aneurismal tumor here exerts upon the nerves, the veins, the
ganglions, the articulation, and all the surrounding parts, renders it a malady
which for a long time was the terror of surgeons, and which was believed,
until the end of the last century, to be wholly beyond their art.
But Van Swieten mentions a case of a traumatic aneurism of this region, which
was spontJaneously cured without the loss of the limb. Mr. Samuel Cooper
108 NEW ELEMENTS OF
also speaks of a patient at St. Bartholomew's Hospital, who recovered, without
treatment, of an aneurism in the arm -pit. Sabatier caused one to disappeai*
by the method of Valsalva and the assistance of refrigerants. Hall, too, towards
the middle of the last century, and Mr. Keate, in 1801, tied the axillary artery
with complete success. Amputation, then, should not be thought of in these
cases ; I do not know that it was indispensably necessary, even in the instance
of diffused aneurism observed in 1812, by M. Debaig, at Val-de grace.
The cures obtained by the efforts of the organization, weakening regimen,
digitalis, purgatives, or cold topical application, appear to me to have been
too few and too much accidental to be counted upon in the way of encourage-
ment. The operation is incomparably more certain, and ougiit always to be
practised when possible. White performed it unsuccessfully : the limb was
invaded by gangrene, but the nervous plexus had been comprised in the liga-
ture. Desault was equally unfortunate, but he had also included in the first
ligature the whole of the brachial plexus. On another occasion, he was not
able to arrest the progress of a hemorrhage, which was quickly mortal. In
the case reported by Pelletan, the whole thickness of the arm-pit was traversed
with a needle, and the artery was not seized. Another attempt of Desault,
which proved equally unsuccessful, is also on record. M.Roux says that a
patient died at the Beaujon Hospital from the consequences of a similar attempt.
M. Delpech, who thought it necessary to cut across the pectoralis minor, and
to raise the whole of the axillary plexus with the fore-finger of the left hand
bent into a hook in order the better to isolate the artery, was also unsuccessful
in 1814. These cases, however, do not prove any thing against the operation 5
the cause of failure was the improper mode of procedure adopted, or else the
untoward circumstances in which the patients were placed.
To the two examples of success mentioned by Hall and Keate, maybe added
a third, t)y M. Maunoir, and two others which have been communicated by
Messrs. Chamberlayne and Monteith.
Art, 3. — Manual.
1. Process of M. Lisfranc. — If a free space remain above the tumor, or if
the operation is for a simple wound in the upper part of the arm-pit, it is better,
according to Messrs. Lisfranc, Hall, and Maunoir, to search for the artery from
the hollow of the arm -pit than to divide the anterior wall of that space.
The patient being placed upon his back, and the limb removed as much as
possible from the trunk, an incision is made of three inches in extent parallel
to the vessels, and a little nearer to the anterior than to the posterior border
of the axilla; the skin, the cellular stratum, and the filamentous aponeurosis
present themselves successively, as in the arm. The remainder of the opera-
tion is performed with the director. With its beak the surgeon pushes the
median nerve forwards and outwards; he then directs it behind the artery in
order to separate it from the ulnar and radial nerves, and raises it a little in
order to pass between it and the vein, which latter he tries with the nail of
the index, or of the thumb of the other hand, to push backwards and inwards.
The patient spoken of by J. Bell had received a stroke from a scythe, and
had fallen into a state of syncope. Hall consequently found it sufficient to
tie the upper portion of tne artery. M. Maunoir's patient had received a
sabre-stroke 5 the wound was simply enlarged. M. M. applied a thread above
and below the wound in the vessel. It is evident that in actual aneurism, the
opening of the sac would here be very dangerous ; too dangerous in fact to be
preferred in any case. When it is not possible to adopt the mode of pro-
OPERATIVE SURGERY* 109
cedure above mentioned, should we penetrate by the front of the arm-pit?
Would it not be better, more prudent, to proceed to search for the subclavian
behind the clavicle, as was practised with success by Mr. Gibbs, or, according
to the method of Brasdor, to apply the ligature below the tumor ? Time and
experience will doubtless solve these questions. I shall only say, in the
meantime, that if the cyst is small enough and high enough to permit the ap-
plication of the ligature between its inferior extremity and the origin of the
circumflex and subscapular arteries, the operator will have every possible
chance of success in conforming to the method of Brasdor; and that in
contrary cases, it is much to be feared that the morbid affection of the arterial
coats will be prolonged to the clavicle, in such a manner as to render the liga-
ture useless upon any point of the axillary trunk. Should the surgeon, how-
ever, notwithstanding the advice here given, resolve upon practising the liga-
ture through the front wall of the axilla, he will find processes enough by which
to effect his purpose.
2. Process of Desault. — M. Roux, after Desault, recommends to incise the
soft parts on the inside of the coraco deltoid line ; afterwards to divide the
pectoralis major upon the grooved director, also the pectoralis minor if neces-
sary, to expose the whole of the brachial plexus, and to take it up between
the thumb and fore-finger of the left hand, in order carefully to isolate it from
the artery as low down as possible. It is not absolutely indispensable to
resort to this mode of procedure, except in operating by opening the aneurismal
sac, and it is probably by inadvertence that it has recently obtained the credit
of being the best method in other cases. If it were indeed prudent or pos-
sible to tie the axillary artery above the tumor at this height, it ought to be
done from the hollow of the arm-pit, and not through the pectoralis muscle.
Although adopted by M. Delpech, in 1814, and since practised by M. Roux,
I cannot consider this method otherwise than as a last resource.
3. Process of Mr. Keate. — The incision of Mr. Keate was oblique down-
wards and outwards. It comprised a part of the pectoralis major without
dividing it entirely, but a first ligature was applied too low ; it was necessary
to place a second very near the clavicle. This would probably not have
happened if, previously to passing a curved needle into the bottom of the
wound, Mr. Keate had taken the precaution to isolate the artery with the
grooved probe.
4. Process of Mr. Chamberlayne. -r-The conduct of Mr. Chamberlayne was
more regular and rational. He thought proper at first to make a transverse
incision of three inches in length in front of the clavicle ; he afterwards made
a second of the same extent parallel to the cellular line which separates the
pectoralis major from the deltoid, turned down the triangular flap formed by
that complex incision, and the artery, which he recognized by its pulsations,
was then exposed : an eyed probe served to pass the ligature. This operation
was performed on the 1 7th of January, and by the 22d of February the cure
was complete.
5. Process of Mr. Hodgson. — Mr. Hodgson rejects the double incision.
According to him and Mr. S. Cooper, the best metliod is to describe a semi-
lunar flap with its convexity downwards, the extremities of which, separated
by an interval of three inches, correspond, the one with the clavicle near the
sternum, and the other with the acromion process. After having raised this
flap, which comprises the whole thickness of the pectoralis major, the upper
triangle of the arm-pit will be found exposed, and the artery may be easily
isolated and taken up between the clavicle and pectoralis minor. Messrs.
Hodgson and Chamberlayne, however, may be reproached with having sacri-
no NEW ELEMENTS OF
ficed to no purpose, a great portion of the pectoral and deltoid muscles. So
that in France, a mode of procedure is now particularly recommended, which
is very similar to that described by Mr. C. Bell, and difters very little from
that of Mr. Keate.
6. Ordinary Method. — The member is at first slightly removed from the
trunk, the shoulder depressed a little backwards. The surgeon, then standing
between the breast and the arm, begins his incision at two fingers' breadth to
the outside of the sterno clavicular articulation,, and prolongs it to a point be-
neath the coracoid process, in the direction of the fibres of the pectoralis
major, taking care to stop at the distance of some lines from the interstice
between the pectoralis and the deltoides. If any little artery present itself
under the skin, the ligature is immediately applied to it ; the fleshy fibres are
gradually separated rather than divided with the bistoury, a very distinct
yellow stratum indicates that the operator has passed through the muscle, the
fibres of which are then relaxed by lowering the member a little, in order
more easily to separate or cause to be separated tlie lips of the wound. If
there be the slightest danger of wounding the vessels, the director or probe
should here be substituted for the cutting instrument ; the operator tears witli
its beak the adipose and cellular stratum and the coraco-clavrcular aponeu-
rosis, whilst the left index finger, bent into a hook, depresses with consider-
able force the upper edge of the pectoralis minor. The operator will soon
distinguish the vein, which may be known by its size and bluish color, or the
first division of the brachial plexus of nerves. In seeking for the artery be-
tween and behind these two cords, the director is guided upon the external side
of the vein, which it is necessary to push a little towards the thorax. The
instrument is then made to penetrate by a to and fro movement to a depth of
from four to six lines, in such a way that in raising it again from rear to front
and from within outwards, it may not fail to bring up the arterial trunk, from
which the operator removes the nerve either with the finger nail or the^beafc
of another director.
By these precautions, the secondary vessels and the nervous cords upon a
dead subject at least, are easily avoided, and the artery with certainty ex-
posed. By placing the ligature immediately under the cephalic vein, the
operator is almost sure to embrace the axillary between the acromials, which
are left above, and the external thoracics which pass below. The supple-
mentary branches which maintain the circulation in the member after this
operation, are the acromial, the subscapular, the transverse cervical, the in-
ternal mammary, and some others of minor importance, all of which form
anastomoses with the circumflex, the common scapular, and the external
mammary.
F. Subclavian.
Art, 1.— Anatomical Remarks.
Several authors have described the axillary artery as formed of two portions;
one, that which I have just examined, situated below the clavicle, the other
placed between that bone and the scaleni muscles. Nothing can justify such
an abuse of anatomical language ; the brachial trunk ought not to take the
name of axillary until it enters the arm-pit ; until then it is the subclavian
artery.
1st. On the inside of the scalenus, the subclavian extremely short on the
right hand, on account of its origin from the innominata, lies by its posterior
OPlfiRATIVE SURGERY. Ill
surface in contact with some filaments of the great sympathetic ; furnishes the
vertebral, and is separated from the triangular space between the longus colli
and the anterior scalenus only by cellular tissue, some lymphatic ganglions,
and the beginning of the recurrent nerve. The pneumo-gastric, the phrenic,
and that branch of the trisplanchnic which connects the second witli the
third cervical ganglion, cross its anterior surface, which is afterwards covered
by the sterno-thyroideus and sterno-hyoideus muscles, several cellural lami-
nae, the internal edge of the sterno-mastoideus, the aponeurotical strata of
the neck, and, lastly, by the common integument. Below it is embraced
by the recurrent nerve, and its concavity is only removed from the lungs by
the pleura, or a little cellular tissue. In this short passage it gives off the in-
ternal mammary, the thyroid, the transverse cervical, the ascending cervical,
the pj'ofound cervical, and the superior intercostal. On the left side it ex-
tends almost vertically from the arch of the aorta to the edge of the first rib,
receding by degrees from the corresponding carotid. The pneumo-gastric
nerve descends upon its internal side ; the recurrent does not cross it behind,
because it is not until after that nerve has turned around the arch of the aorta
that it reascends towards the trachea. The thoracic duct approaches very
near its posterior surface, and commonly hooks around it above to empty
into the subclavian vein. This vein, which is separated from the artery by
a considerable interval, crosses it at some distance, whilst on the right "it is
principally covered by the termination of the internal jugular.
2d. After it has become horizontal, the subclavian holds the same relations
on either side, and lies immediately on the first rib. The inferior attachment
of the anterior scalenus separates it from the vein, and this from the sternal
portion of the sterno-mastoideus muscle ; all the nerves of the brachial plexus
are above and behind, so as to form, by prolonging themselves upon the an-
terior surface of the posterior scalenus^ a sort of lattice-work, of which the ar-
tery is the lowest bar.
3d. On the outside of the scalenus it corresponds to the hollow above the
clavicle, rests upon the first intercostal space, the second rib, and the first
fasciculus of the serratus magnus muscle. The vein approaches and covers
it, descending a little towards the clavicle; receives there the subscapular,
the external jugular, and sometimes the acromial vein, from which results
in certain cases a somewhat complicated plexus. Its superior side is accom-
panied by the united cords of the last cervical pair and the first dorsal ; a
little farther off by the other branches of the brachial plexus, which soon pass
behind, so that it is found constantly in the triangular space, bounded by the
omo-hyoideus on the outside, the clavicle below, and the anterior scalenus
muscle on the inside. In returning towards the skin, the operator will
meet with lamellar and adipose and filamentous masses, with lympathatic gang-
lions, small veins, the supra-scapular and posterior cervical arteries, many
nervous branches of the cervical plexus, a very irregular aponeurosis, and,
near the sternum, the external root of the sterno-mastoideus muscle, the su-
perficial veins, and some scattered fibres of the platysma myoides.
Anomaly. — ^I shall add to the above details, already perhaps too minute,
that the vein has been seen with the artery between the scaleni muscles ;
and again, that the artery has passed to the place of the vein, and that I have
myself witnessed both these anomalies. When the small scalenus muscle
exists, it may, as has been remarked by M. Robert, in attaching itself to the
rib, separate the two inferior cervical nerves from the superior branches, and
incline them forwards and towards the vessels ; at other times the artery
may be completely isolated by it froni all the nerves. It is possible, also,
112 NEW ELEMENTS OF
that the vein may be more than usually high above the clavicle — may be di-
vided into two trunks, as observed by Morgagni, and may entirely hide the
artery, which is sometimes, though rarely, environed on all sides by the bra-
chial nerves. The occasional presence of a small muscle fixed by its two
extremities upon the clavicle, the attachment of the sterno-hyoideus to the
inside of the sterno-mastoideus, the insertion of a second root or the inferior
border of the omo-hyoideus muscle in the clavicle, are also anomalies of
which the surgeon ought not to be unapprised.
Art. 2. — Surgical Remarks,
The subclavian, sheltered as it is by the clavicle, partly enclosed within
the breast, protected at least by the sides of this cavity, is but little exposed
to the influence of external agents; removed also from the alternations of
flexion and extension to which the axillary and popliteal arteries are sub-
jected, it is thus free from one of the most frequent causes of spontaneous
aneurism. Nevertheless, it is not entirely exempt, but is sometimes affected
by the maladies to which the other arteries are subject. M. Larrey relates
two examples of its being wounded by sharp weapons. In a third case the
wound was followed by a varicose aneurism.
In all cases, it is less for lesions of itself than for those of the axillary, that
ligature is applied upon the subclavian artery. When an aneurismal tumor
in fact develops itself in the supra-clavicular hollow, however small may be
its volume, it soon becomes impossible to place a thread between it and the
heart, upon the trunk which it affects. If an aneurism at the hollow of the
arm-pit, on the contrary, enlarge so as to raise the shoulder, the ligature is
applied above the clavicle. Aneurisms which might be cured by the ligature
of the subclavian, sometimes disappear spontaneously, as in the case published
by M. Bernardin. The method of Valsalva, refrigerants, &c., would also,
without doubt, occasionally arrest the progress of the malady. M. Richarme,
in his thesis, cites an example of cure obtained by such means. As it is dan-
gerous, however, to permit the tumor to increase in size, and as the results of
the above resources are always problematical, it is most advisable to operate
as speedily as possible.
The ancient method is not here applicable. If it is not possible to apply
the method of Anel, that of Brasdor is the only one which can supply its place;
and the operation is then not ligature of the subclavian, but ligature of the
axillary for aneurism of the subclavian.
M. Dupuytren was the first who performed this operation upon a living
subject. The patient it is true died at the expiration of nine days (20th July,
1822), but instead of increasing as might have been feared, the tumor was
sensibly diminished in size, and lost in a great measure its pulsation; in
short, numerous bleedings and a hemorrhage by a supplementary branch
(which was at first supposed to proceed from a wound of the principal artery^^
seem much more than the operation itself to have been the cause of deatn*
It must be confessed however, that the axillary offers fewer facilities than
any other artery for the practice of the method m question. The numerous
branches which arise from it are so many channels by which the blood will
continue to circulate, and will hinder the resolution of the aneurism, unless
they have been previously obliterated by the accumulation of fibrin or by
the progress of the tumor. Tiie branches also which are given oft' by the sub-
clavian artery to the inside of the scalenus, will, wherever the malady reaches,
thus far constitute an equally powerful obstacle to the success of tliis mode of
OPERATIVE SURGERY. 113
operation. Yet as it is possible to apply the ligature very near the cyst,
and internal concretions may have diminished, or even completely obstructed
the calibre of these arteries, and as the last resistance to the course of the
blood suffices to determine its coagulation in the morbid sac, I believe that
it would be perfectly justifiable to repeat the operation performed by M.
Dupuytren.
Art, S. — Manual.
Ligature of i}\e subclavian artery, according to the principles of Anel, has
been practised upon three different points of its length, viz. within the sca-
leni, between the scaleni, and without those muscles.
1. Process of Mr. Colles. — CoUes is the only individual to my knowledge
who has ventured to expose and tie this artery between the trachea and
the anterior scalenus muscle. Great difficulty was experienced in passing
the thread round the artery, and it was thought that the pleura had been
slightly wounded. Before fastening the thread the respiration became very
laborious, and the patient complained of a sense of oppression at the heart.
These symptoms became so serious that it was not deemed advisable to
tighten the ligature until the fourth day. The patient found himself very
well until the ninth dsij, when he again experienced a feeling of strangulation
and great pain in the cardiac region ; he then became delirious, and expired in
about nine hours from the commencement of these symptoms. On opening
the body, the aorta was found to be diseased as well as the whole extent of
the subclavian artery.
2. Another Process. — In order to reach this point of the arterial trunk, (if it
is not thought advisable to imitate the process of Mr. King*), the operator
should cut across upon the director the clavicular portion of the sterno-mas-
toideus muscle, depress the internal jugular vein towards the trachea, the
subclavian vein downwards and forwards upon the clavicle, and push aside
the carotid artery, and the phrenic and pnemuo-gastric nerves. On the left
the operation is rendered more formidable by apprehensions of injury
to the thoracic duct, as well as by the necessity of penetrating much more
deeply.
But it is not impossible to place the ligature between the origins, of the
mammary and vertebral arteries, &c., and the heart; whilst on the right, the
neighbourhood of the innominataswould render such an attempt very dan-
gerous. In every way, ligature of the subclavian artery between the scaleni
and the trachea must prove difficult and formidable. It ought not even to
be practised between these muscles, unless the state of the parts should be
such as to render it impossible to operate on the outside. Not that it is ex-
tremely difficult, or that it would be surely unsuccessful, but because the ad-
vantages which it promises may be otherwise and more easily obtained, and
because the section of the scalenus, which is in itself a disadvantage, also
exposes the operator to the danger of wounding the internal jugular vein, or
the subclavian itself, as well as the two respiratory ner\'es.
3. Process of M. Dupuytren. — The following is the method recommended
by M. Dupuytren, who is said to have practised it several times with success,
particularly in 1819 : — A transverse incision is made at the base of the neck,
from the anterior edge of the trapezius muscle to the external edge of the
sterno-mastoideus, and is even a little prolonged upon the external surface of
the latter. Having found the anterior scalenus, the operator directs between
* See further on Innominata.
15
114 NEW ELEMENTS OF
its posterior side and the arterj the extremity of a grooved director, upon
which he divides its fibres. By the performance of this single section, the
vessel is exposed and completely isolated* The posterior scalenus muscle
serves as a guide to the needle-probe which bears the ligature.
4. Process of Mr, jRawisden.— The subclavian artery ought to be, and most
commonly has. been tied in the omo-clavicular triangle, or on the outside of
the scaleni muscles. Mr. Ramsden, who was the first to perform the ope-
ration in a regular manner, proceeded as follows : — He in the first place
made a horizontal incision an inch and a half long, just above the clavicle;
then another incision two inches in length, parallel with the external edge of
the sterno-mastoideus muscle, and meeting the extremity of the first. After
having lowered the shoulder, Mr. Ramsden continued the dissection of the
tissues so as to expose the edge of the anterior scalenus. The artery was
then easily found ; having isolated it with the nail, he endeavored to pass the
ligature around it. Numerous difficulties presented themselves. It became
necessary to make use. of several instruments, and it was not until after mul-
tiplied attempts, that he was at last able to finish the operation. The patient
died on the sixth day (9th or 10th November). Some time previously, Sir A.
Cooper had attempted, but in vain, to take up the artery ; he took up a nerve
instead of it, and the patient died shortly afterwards of hemorrhage. In the
month of April or May, a woman of about sixty years of age was admitted
into the Hotel Dieu, at Paris, with an enormous aneurism in the axilla. One
of the surgeons of the establishment was of opinion that ligature of the sub-
clavian ought to be, and miglit be practised ; the other was of the opposite
opinion, and the patient died in a few days without having undergone an ope-
ration. This circumstance however occurred some time after the attempt of
Messrs. Cooper and Ramsden, so that the merit of priority in this idea re*
mains with the English practitioners.
A patient, very aged and feeble, operated upon by Mr. W. Blizard, in 1811,
died on the fourth or fifth day. A similar result was experienced by M. Galtie,
at Montpeliers, in 1814. Messrs. T. Blizard and Colles were equally un-
successful in 1815; but complete success crowned the efforts of Mr. Post, in
1817, and afterwards those of Messrs. Dupuytren, Liston, Bullen, Green,
Gibbs, Key, Roux, Langenbeck, Mott, Porter, &c.
5. Process of Mr. T. Blizard. — The modes of operation adopted by the
above gentlemen, differed very little from each other. Mr. T. Blizard made
an incision three inches in length, parallel with the external jugular vein at
the bottom of the neck, and towards the acromion. Mr. Post divided the
tissues in the direction of a line slightly oblique in reference to the clavicle,
and beginning at the external edge of the sterno-mastoideus. Mr. Porter
made a horizontal incision above the clavicle, then a vertical incision on the
outside of the sterno-mastoideus muscle, and turned backwards the triangular
flap thus formed. M. Dubled, on the contrary, recommends that the incision
be made in an oblique direction downwards and inwards, so that it may fall
near the sterno- clavicular articulation. According to Mr. Hodgson the inci-
sion should be exactly transverse ; and his method certainly offers more
advantages than any other. I do not think that the proposal of a member of
the Surgical Academy, to include in the same ligature both the artery and
the clavicle, has ever been renewed ; and I am at a loss to conceive what
reasons could induce M.Cruveilhier to say, in his course of anatomical studies,
that it would be useful to saw that bone in order with greater security to tie
the subclavian.
6. Ordinary Process. — The patient should be placed upon his back with
OPERATIVE SURGERY. 115
the breast a little elevated ; he is made to turn the head and neck towards the
sound side, while an assistant depresses the shoulder as far as the aneurism
will permit, removing at the same time the arm from the trunk. The integu-
ments are then cut in a transverse direction, at an inch above the clavicle,
from the external edge of the sterno-mastoid muscle to the inner border of the
trapezius. The operator then divides in the same direction the cellular
tissue, the fibres of the platysma myoides, and the external jugular itself
(after having tied it above and below the point of division), if there be no pos-
sibility of avoiding it by holding it aside by means of a blunt hook ; he after-
wards divides the aponeurosis, and with the fore-finger will then be able to
distinguish the edge of the scalenus immediately beneath, and within the
sterno-mastoideus. After having removed the cellular tissue, the lamellae,
the filaments, and the ganglions, from the bottom of the wound, with the end
of the director or a good dissecting forceps, the finger is carried towards the
root of the scalenus to find the tubercle of tha first rib. This tubercle is here
a sure guide ; so much so, that if without leaving it the pulp of the fore-finger
is turned a little outwards and backwards, it will almost invariably feel the
vessel. AYhen the vessel has once been found, the eye is no longer necessary.
The nail applied against its posterior and external side, serves as a conductor
to the bent probe or needle. By directing the beak of one of these instru-
ments backwards and a little outwards, it is soon properly placed under the
artery. The operator then, in order to hold the artery and prevent it from
altering its position, places his finger between it and the first division of the
brachial plexus of nerves.
When the shoulder is not too much deformed or elevated by the tumor, or
can be depressed without inconvenience, any surgeon who has a little prac-
tical knowledge of anatomy may apply the ligature without the difficulty
which is generally supposed to attend the operation. The section of the
omo-hyoid muscle, proposed by some surgeons, and that of the sterno-mastoid,
still practised by Mr. Mayo, are utterly useless. The action of the director,
which ought to be preferred after the division of the aponeurosis, enables the
operator to avoid injuring the plexus formed by the confluence of the little
veins of tlie shoulder and the neck when they arrive at the subclavian.
To avoid injuring the latter it is sufficient to carry the extremity of the con-
ductor beneath it and next the scalenus, before bringing the instrument back-
wards to hook up the artery. Finally, as this vessel in the normal conform-
ation is invariably the first movable cord which presents itself under the
finger after leaving the tubercle of the first rib, and as the nerves are distin-
guished from it by their roundness and firmness, it is almost impossible that
the operator can commit an error.
Results of the Operation. — Mortification of the member, which appears so
much to be apprehended after the obliteration of the subclavian, seldom
takes place. A sense of suffocation, delirium, and symptoms of affection of
the cerebrum,, of the heart, and its envelope, were observed in the patients of
Messrs. Ramsden, CoUes, Blizard, Mayo, Gibbs, &c. After death traces of
pericarditis were discovered 5 the aorta and the heart w^ere also diseased,
but there was no appearance of gangrene. In some cases the circulation re-
establishes itself with remarkable rapidity ; pulsation reappeared in the radial
md cubital arteries of Mr. Roux's patient the morning after the operation.
The blood is brought back into the axillary or the brachial by the anastomoses
of the internal mammary with the thoracics, and of the acromial and the com-
mon scapular with the posterior cervical and the supra-scapular. If the
ligature is applied to the inside of the scaleni, above the vertebral and mam-
116 NEW ELEMENTS OF
mary arteries, the fluids can only reach the limb of the diseased side by the
communication of its vessels with those of the healthy side.
Wardrop tied the subclavian artery upon the plan of Brasdor, for an aneu-
rism of the innominata. The corresponding carotid artery, which had been
previously obliterated by the tumor, soon became pervious again. The ope-
ration appeared at first to be completely successful 5 but after a few days the
aneurism made renewed advances, and the patient (Madame Desmarest) sank
on the 13th Sept. 1829. I shall revert to this fact in another place, and shall
content myself at present with remarking, that the best method of treating an
injury or disease of the subclavian is to place a ligature upon the artery
immediately below rather than above the clavicle.
SECTION III.
ARTERIES OF THE HEAD.
There is hardly a branch of any importance, whether upon the face or upon
the cranium, but is subject to injury by external agents, or may become the
seat of one of these spontaneous aneurisms which are characterised as mixed
or true. Paletta cites one example, and Scarpa two, of aneurism of the tem-
poral artery. Mr. Green has lately made known a fourth. Klaving speaks
of one which occupied the left posterior auricular. The subject was a young
man, twenty-five years of age. Dehaen witnessed a similar aneurism upon
the dorsal artery of the nose. M. Godichon, of Versailles, saw a pediculated
aneurismal tumor upon the forehead, more than an inch in thickness ; he also
observed another in front of the right tuber-parietale. The Leipsic trans-
actions contain an observation of aneurism of the frontal artery. M. Gaste
and M. Merat, speak of aneurism at the temple. M. Gama cured one which
was seated near the commissure of the lips. M. Begin cites another which
was seated upon the middle meningeal, and which caused the death of the
patient after having perforated the temporal fossa. M. Krimer reports a
similar fact. Pelletan mentions an aneurismal or erectile tumor on the eye-
lid— the patient a boy; also another upon the conjunctiva of a second subject;
and a third upon the upper part of the forehead. He has seen also, in two
different cases, almost all the branches of the occipital or temporal, and even
the external carotid, dilated and in a state of hypertrophia, as in varicose
aneurism. The palatine artery itself is not exempt from these aneurismal
dilatations, as has been proved by an observation of M. Delabarre. As to the
arteries within the cranium, they are, though less frequently, subject to the
same maladies as those of the exterior. Examples of varicose aneurism, or
of aneurism by anastomosis, occurring about the globe of the eye, have been
published by Messrs. Wardrop, Travers, Arendt, &c. Sir A. Cooper observed
a small aneurismal tumor upon the central artery of the retina. M. Serres
describes another, as large as a nut, which was attached to the basilary, and
Mr. Hodgson reports a case in which a small sac, formed by the anterior cere-
bral artery, was completely filled with a solid coagulum, which did not extend
into the cavity of the vessel. But in cases of this kind one of two things is
always true 5 either the aneurism is completely enclosed in the cranium so
that nothing can indicate its presence and the resources of surgical skill are
of course ot no avail, or the malady displays itself upon the exteiior ; and if
compression is not found to be sufficient, and the opening of the sac is not to
be attempted, although once successfully performed by M. Cisset, upon the
OPERATIVE SURGERY. 117
occipital artery, ligature of the carotid is ordinarily preferred to that of the
artery which is more particularly affected. There is scarcely any exception at
the present day in this respect, unless it be for the trunk of the facial and tem-
poral, or unless it should be possible to act upon the injured part itself.
A. Temporal.
The temporal artery is easily found at three lines in front of the ear, a little
above and upon a level with the zygomatic arch. An incision of an inch in
length is enough to conduct to it, and it is found enveloped in the deep laminae
of the subcutaneous cellular stratum.
B. Facial.
It would not be difficult to expose the facial at the place where it begins
its course over the inferior maxilla. By cutting the skm with caution, upon
the edge of that bone and in a horizontal direction, from the anterior edg3 of
the masseter to the edge of the depressor anguli oris, it is immediately exposed.
It may also be reached by dividing the parts which cover it, to the extent of
an inch or an inch and a half, obliquely from above downwards and back-
wards, close to the masseter muscle ; its satellite vein is the only organ which
requires care, and even this might be wounded or compressed in the ligature
without producing any serious inconvenience.
The occipital should be sought for in the neck.
SECTION IV.
ARTERIES OF THE NECK.
A. Primitive Carotid.
Art. 1. — Anatomical Remarks.
After leaving the breast, the carotid artery soon places itself upon the side
of the passages of respiration and deglutition, where it remains until its bifur-
cation, whicn generally occurs opposite the thyro-hyoidean interstice. The
internal jugular vein is joined to its external face, and in the living subject
even partly hides its anterior surface. On the inside, some elastic and resist*
ing cellular tissue and branches of the recurrent nerve and of the inferior
thyroid artery, separate it from the larynx, from the trachea, and from the
oesophagus. The thyroid artery below the cardiac branches of the pneumo-
gastric nerve, and the internal divisions of the great sympathetic, cross more
or less obliquely its posterior surface, the external side of which is also accom-
panied throughout its whole extent by the trisplanchnic and pneumo -gastric
trunks. A yellow sheath, very solid and difficult to tear, incloses it with the
vein, the nervous cords, and the descending branch of the hypoglossal nerve,
which usually follows down its anterior and external face. This artery lies
upon the forepart of the cervical vertebrae, from which it is separated by the
longus colli and the rectus anticus major, and it is covered on the outside and
near its root by the sterno -mastoid muscle, which soon removes from it so as
to leave it uncovered on its internal side ; and on the inside by the external
edge of the sterno-hyoid and sterno -thyroid muscles, then by the correspond-
ing lobe of the thyroid gland and the veins (sometimes of considerable size),
which come from tlie face and neck to pour their contents into the internal
118 NEW ELEMENTS OF
jugular. It is, moreover, divided as it were into two portions by the omo-
hyoid muscle, towards the middle of the sub-hyoid region. This small mus-
cle, in fact, forms of the side of the neck two very regular triangular spaces,
by its passage from the posterior surface of the sterno -mastoid to the os-hyoides.
In the inferior, or omo-tracheal, limited by the trachea, the clavicle, and the
muscle in question, the artery hidden by the internal root of the sterno-mas-
toidean has no very complex relations, although it is very deeply situated ;
in the other, which is bounded by the edge of the sterno-mastoid on the out-
side, the transverse line which limits the sub-hyoid region above and the omo-
hyoid muscle below, it is much more superficial. But there a plexus of veins
frequently covers its anterior surface. The right carotid, which is shorter as
is well known than the left, on account of its origin from the innominata, and
which is also sensibly nearer the median line and more superficial because
of the trachea which pushes it forwards near the sternum, is almost as easy to
reach in the omo-tracheal space as in the omo-hyoid triangle.
Anomalies. — Among the varieties presented by the carotid arteries, are
some, the possibility of which ought never to be lost sight of by the surgeon.
That of the right side many come directly from the aorta. At other times,
the innominata rises higher than usual, of which Mr. Harrison cites an in-
stance ; and it is sometimes as much abridged in length. Zagorsky has seen
the left carotid and subclavian originating by a common trunk ; at the right
they arose separately from the aorta. I have myself seen, as well as Messrs.
A. Monro, Scarpa, A. Burns, Goodman, Meckel, &c., both carotids proceed
from the innominata, and in other cases given off by a common trunk which
came from the aorta distinct from the subclavian arteries. But it is rare to
see them separate into the internal and external carotids in the inferior part
of the neck, as has been observed by Burns and others. An instance of this
variety was observed last winter, in the anatomical rooms of the Jefferson
Medical College in Philadelphia. M. Lan^enbeck saw the primitive carotid
divided into the internal carotid and superior thyroid, without furnishing an
external carotid ; and Burns cites examples of the carotid trunk bifurcating
on a level with the angle of the jaw.
Art. 2. — Surgical and Historical Remarks.
Aneurisms. — The primitive carotid has presented examples of every species
of aneurism. It is but too common to see it injured by penetrating or cutting
instruments, and giving passage to hemorrhage which promptly becomes mor-
tal. Sometimes, however, the wound merely occasions an aneurism at first
diffused, but afterwards circumscribed. Harder relates a case of this kind
where the carotid had been wounded by the point of a sword ! at other times
aneurism is produced by violent motions of the head. Rumler saw this occur
upon a man, who in attempting to lift a heavy burden, forcibly held back his
head. Scarpa speaks of a similiar fact; the subject, who was a soldier, had
been precipitated from the walls of Mantua, and experienced a violent twisting
of the neck. Aneurism of the carotid may also develop itself without any
apparent cause, as it has been observed by Scarpa, and proved by numerous
modern examples. Messrs. Larrey and Desparanches, of Blois, have witnessed
varicose aneurism at the carotid. Lesions of arteries so voluminous, the only
ones which supply the exterior of the head and the greater part of the ence-
phalon, naturally produced considerable alarm in the minds of surgeons from
tlie time when it became known that, in order to effect a cure, it was neces-
sary to obliterate the injured vessel.
OPERATIVE SURGERY. 119
Galen and Valsalva, it is true, had previously ascertained that ligature
of the carotid arteries of dogs was not dangerous; but they Avere far from
thinking of the performance of such an operation upon a human subject. To
dissipate the doubts of the faculty upon this point, other facts were neces-
sary. In the case of a man, who died seven years after the cure of an
aneurism of the neck, M. Petit found the right carotid completely obliterated ;
Haller, in dissecting the body of a female, observed a similar state of the left
carotid ; Baillie found one of the carotids entirely closed, and the other con-
siderably contracted. Pelletan and Sir A. Cooper relate each a similiar
case ; and if Koberwin may be believed, M. Jadelot saw both arteries oblite-
rated on the same subject. These examples, added to those which have been
observed of late years, particularly one which came under my own observa-
tion last winter at the dissections of the practical school, prove two things:
first, that one of the carotid arteries, and even both, may be completely
closed without producing death, and without cutting oif the supply of blood
from the brain : secondly, that aneurism of the carotids is not always be-
yond the resources of the organism, but that if abandoned to itself, it will in
certain cases spontaneously disappear. But it is absurd to attempt the cure
of aneurism of these arteries (excepting by the method of "Valsalva or refri-
gerants, as used with some success in our own time, by M. Larrey), without
renouncing the old method. It seems to be impossible to establish at the
neck a sufficient degree of compression to allow the opening of the sac with
perfect safety. The surgeons of La Charite, who, according to Harder, had
the temerity to adopt this method, saw their patient die under their hands.
According to Hebeinstreet, cited by S. Cooper, the carotid had already been
tied with success for a wound which had occurred during the extirpation of
a scirrhous tumor from the neck ; also by Abernethy, with equal success, for a
traumatic lesion of the external and internal carotids. In 1803, Mr. Fleming
was equally fortunate with a mariner who had attempted suicide. The
journal of Sedillot contains a fourth example of this operation performed for
a wound in the neck : the patient died on the 9th day. Mr. Brown makes
known a fifth, which was followed by cure. Mr. Collier furnishes a sixth,
authenticated by Mr. S. Cooper ; and the treatise of Mr. Hodgson contains a
seventh. Anel, V. Home, and M. Larrey, also each cite an example of wounds
of the carotid, cured by simple compression.* In November, 1805, an
aneurism of the carotid was treated for the first time by the method of Anel.
The patient died on the twentieth day. Sir A. Cooper again had recourse
to this method in the month of June 1808, and on that occasion with complete
success. In the September following, a patient operated upon in the same
way by Mr. Cline, at St. Thomas's Hospital, died on the fourth day. It
was not until this time that the surgeons of Paris became acquainted with
the attempts which had been made in London, and learned that in the year
1804 M. Dubois had prepared every thing for a similiar attempt, which,
however, could not be made, in consequence of the patient having expired
the evening preceding the day appointed for the operation. In our own
time it has been practised by a great number of surgeons, sometimes with
and sometimes without success, either for the purpose of permitting the
amputation of the maxilla, or the extirpation of the parotid or of cancerous
or fungous tumors, as in the cases of Messrs. Lisfranc, Gensoul, Walther,
Fricke, M'Clellan, &c.; to cure erectile tumors, or fungous hematodes of the
eye, as it has been successfully done by Messrs. Travers, Dalrymple, Arendt,
&c. 5 for simple wounds of the face or neck, as by Messrs. Langenbeck»
• Was the carotid really the seat of the disease ?
120 NEW ELEMENTS OF
Baffin, Lisco, &c. ; or finally, for aneurisms, properly so called, of the carotid
or its branches. Mr. Pattison practised it with complete success in 1821,
for an aneurism by anastomosis, or an erectile tumor of the zygomatic
fossa, upon a subject of about nineteen years of age. The infant aged six
weeks, upon whom Mr. Wardrop -performed the operation for a fungous ulcer
of the cheek died on the fourteenth day. In'Mr. Roux's patient, the fungus was
considerably diminished in the orbit, and reduced to the part which existed in
the temporal fossa. M. Dupuytren's patient derived no benefit from this
operation, which was performed for an erectile tumor in the concha. M. Wil-
laume was equally unsuccessful with a subject afiiicted with fungous hematodes
of the left temple. Mr. Massey, who tied successively the two primitive
carotids for an enormous bloody tumor of the vertex, obtained only an
incomplete reduction of the fungus, and was obliged eventually to have
recourse to extii'pation. In the case of an infant laboring under a similar
aftection of the face, Dr. M'Clellan, who is said to have performed the opera-
tion four times in one year, obtained some advantage. Ligature of the carotid
has been successful in forty out of sixty cases which have been published.
It ought, therefore, to be admitted among the number of the most important
acquisitions to the surgery of the present age. It has even been practised for
mere pains in the face, but the operator in this case acknowledges, in the
supplementary journal, that the sufferings of his patient were not alleviated
by the operation.
Art. 3. — Manual.
Ligature of the carotid trunk is usually an easy operation, but practitioners
differ a little as to the best manner of performing it.
1. Ordinary Process. — The patient should be placed upon his back, with
the breast a little elevated, the neck moderately extended, and the face in-
clined towards the unaffected side. Standing on the same side with the
aneurism, the surgeon seeks the anterior edge of the sterno-mastoid muscle,
which is indicated by a slight depression. He then, in order to discover the
artery in the omo-tracheal triangle, makes an incision in the direction of this
edge of about three inches in length, commencing at the level of the cricoid car-
tilage, and terminating near the sternum ; but he makes the incision higher up,
though in the same direction and with the same ffuide, whenever the malady
permits the ligature of the artery in the omo-hyoid triangle. A second stroke
of the bistoury divides the platysma and the cervical aponeurosis, and exposes
the fibres of the sterno-mastoid muscle. The assistant draws the internal
lip of the wound towards the median line. The operator holds the external
and muscular lip outwards by means of the index and middle finger of the
left hand, restores the head to its natural position, and afterwards incises the
fibro-cellular stratum, which extends from the sterno-hyoid and sterno-thyroid
muscles to the posterior face of the sterno-mastoid, and passes over the front
of the vessels. The omo-hyoid muscle then presents itself in the shape of,
a narrow reddish band ; if it be much in the way it is divided upon the di-
rector, but it is generally easy to preserve it by drawing it to either side with
the finger, a blunt hook, or with the extremity of the probe. Above and
below are seen the vein and artery enveloped in their common sheath, the
anterior wall of which incloses the descending branch of the ninth pair.
This sheath should be at first perforated opposite to the artery, and not the vein,
with the beak of the director ; it should then be divided upon the same in-
strument with the bistoury, to the extent of an inch or two. When the jugular
OPERATIVE SURGERY. 121
becomes so much distended, during inspiration, as to conceal a part of the
carotid and embarrass the operator, compression applied at the superior angle
of the wound will immediately remove this difficulty. The probe, held like
a pen, is then directed between the two vessels ; one or two fingers of the
opposite hand fix the artery and prevent it from slipping towards the trachea,
whilst by gentle movements to and fro and pressure upon the point of the
instrument, the operator passes it along the posterior surface so as to raise
the artery without violence, and without touching the pneumo-gastric or sym-
pathetic nerves or any of their branches.
Remarks. — In falling at first to the inside of the sterno-mastoid muscle,
the operator incurs the risk of mistaking its fibres for those of the sterno-hyoid
and thus deceiving himself; it is better, therefore, to commence the incision
upon its external surface, some lines to the outside of its edge: it may after-
wards be easily brought back to the ed»e of the wound in the integuments.
As the coats of the vein are extremely thin and easily torn or dividea, and as
the wound of such a vessel is extremely dangerous, it is of the highest im-
portance that it should not be approached by the bistoury. For the rest it is
easily distinguished by its black or bluish color, since that of the artery is
grey or yellow. In isolating the latter there are two dangers to be avoided,
viz.; by not isolating it sufficiently from its sheath, the operator incurs the
risk of comprising in the same thread either the cardiac nerves or the branch
of the hypoglossal; by isolating it too carefully, on the other hand, it is pos-
sible to destroy its vasa vasorum, to denude it of its cellular tissue, and to
render it liable to be easily cut by the ligature. It is scarcely necessary to
observe, that the vagus nerve is between the posterior laminae of this sheath
in the fossa between the artery and the vein. To recapitulate all the dan-
gers which may result from its being injured, suffice it to say, that the parts
should be sparingly separated, that the artery should be tied alone but with-
out being too much denuded, and above all, that one of the conditions of suc-
cess in this operation is the being able to obtain an immediate reunion.
Should the jugular vein unfortunately be opened, I do not know that it
would be better to tie it than to stop the hemorrhage by thrusting pieces of
lint into the wound. Mr. Simmons, of Manchester, applied the ligature
without inconvenience it is true, and stoppage of the hemorrhage as above
mentioned, would produce irritation and render it necessary to have the
wound open ; yet to say nothing of phlebitis, which is there the most to be
apprehended, what consequences miglit not result from the obliteration of so
'voluminous a vein at the same time with the principal artery of the head ? If
the lesion were trifling it would be better to pinch together the lips, and en-
-circle them with a thread in such a way as not to close the calibre of the vessel.
The patient thus treated by Mr. Guthrie did not die until after another ope-
ration, which was practised some time after the first.
2. Process of M. Sedillot. — In order to fall perpendicularly upon the ar-
tery, to have a neater incision of less depth, and which would allow an easier
issue to the fluids, M. Sedillot has recently invented a new mode of tying
the carotid at the inferior part of the neck. His incision, directed much more
outwards than in the ordinary process, falls upon the external surface of the
sterno-mastoid muscle, of which he passes through the whole thickness be -
tween the two points of origin. The lips of this wound being separated by
an intelligent assistant by means of the fingers or of hooks, the operator will
find himself immediately above the vein and the artery, and has nothing to
do but to separate them. This method is feasible and ingenious; but upon a
living subject, on account of the jugular vein, and the contractions of the
16
122 . NEW ELEMENTS OF
divided muscle, it would be, I apprehend, less easy and less sure" than the me-
thod before described. Consequently I am of opinion that it ought not to be
adopted, particularly as the inconvenience which M. Sedillot desires to evade,
is scarcely to be apprehended if the operation be well performed.
Results of the Operation* — When the carotid is obliterated, the circulation
soon completely re-establishes itself in the corresponding side of the neck
and head; the voluminous and almost innumerable anastomoses which it
forms in the brain with the vertebral and internal carotid of the opposite
side; those whicLare formed by the temporal, the occipital s, the supra-
orbitals, the facials, the Unguals, the thyroids both superior and inferior, and
in short all tlie branches of the external carotid, form so large a net- work that
the operator need not entertain the least inquietude on this point; it is rather
to be feared, in fact, that these resources, so precious and so long neglected,
may Compromise success, by conveying too great a quantity of blood into the
tumors after the operation. This is an inconvenience which actually occurs ;
the pulsations of the aneurism have been remarked to diminish at first, but
have afterwards returned, and continued for several weeks. In the case of
the patient operated upon by Mr. Walther, for an aneurism of the external
carotid, they continued two months. It would be difficult to comprehend,
if observation had not demonstrated that the ligature of the primitive carotid
should be able to eifect the cure of aneurismal affections of arteries so remote
as those for example, of the orbit, or of the face, or of the outside of the cra-
nium ; but it has been proved in our day that this reflux does not always
prevent the resolution of the morbid tumor, and that topical refrigerants and
compression suffice to determine that resolution, or at least to hasten it. The
success obtained by Mr. Mayo by the aid of this operation, in a case of hemor-
rhage by an ulcer of the pharynx, another mentioned by Mr. Lucke, occasioned
by a pharyngeal or laryngeal hemorrhage, the source of which could not be
precisely ascertained, offer still further proofs of the correctness of this
doctrine.
B. Internal and External Cai'otids.
Neither the internal nor the external carotid is ever tied, nor tbe occipital,
below the head, unless they present themselves in a wound 5 not that such an
operation is impracticable, or even difficult, but because it i& seldom possible
to decide whetner the aneurism belongs to this or to that branch, and because
the same result may be obtained, with greater certainty and less danger, by
applyiuj^ the thread upon the primitive trunk itself. Still the neck presents
some other branches which it may become necessary to tie ; the external max-
illary and the lingual for example, in operations upon the maxilla or the
tongue ; the superior and inferior thyroids in various maladies of the gland
from which they take their name ; and even the vertebral, when it does not
enter its canal until it arrives at the fifth, fourth, or third vertebra.
C. Facial or External Maxillary.
To expose the facial artery an incision should be made of two inches in
length, parallel to the inner edge of the sterno-mastoid muscle, its middle
point corresponding with the greater horn of the thyroid cartilage. After
having divided the skin, the platysma myoides and the cervical aponeurosis,
removed the muscle, and exposedi the carotid itself, the sheath of that vessel
should be divided with the channeled probe on its anterior side, ascend-
OPERATIVE SURGERYr 123
ing towards the os-hyoides. The operator will there find the origin of
the external artery of the face, which passes obliquely inwards and upwards,
so as to gain the submaxillary gland and the inferior border of the jaw.
The same process is applicable to the lingual artery, which is a little more
deeply situated, and which begins by running horizontally before it takes
a vertical direction between the hyoid bone and the muscles of the tongue.
D. Thyroids.
The thyroid arteries have been tied by several practitioners, particularly
Messrs. Walther, Heden, Coates, and Langenbeck, in order to permit the
extirpation of the thyroid, or to produce atrophy of that body, in cases of
scirrhus or of goitre.
Operation. — Superior Thyroid. — An incision is made as above ; and as
soon as the sterno-mastoid muscle is withdrawn from the larynx, the operator
will see, in the omo-hyoid space, the jugular vein and the primitive carotid ;
after having divided the fibro-cellular lamellas which cover and connect these
vessels, the thyroid artery, although deeply situated, is seen exposed between
them and the corresponding lobe of the thyroid gland. It is occasionally
hidden by some small veins, from which, however, it may be always isolated
with the channeled sound,* and the more easily as the operator approaches
more nearly the trunk where it originates.
Inferior Thyroid. — The incision ought here to be made in the same way as
for ligature of the carotid at the bottom of the neck. The thyroid artery,
coming from the subclavian, passes behind the internal jugular vein, the
pneumo-gastric nerve, and the carotid artery, ascending afterwards obliquely
to the posterior face of the corresponding lobe of the thyroid gland. It is
commonly concealed by the superior portion of the omo-hyoid muscle. It is
necessary then to divide or depress that muscle, in order to reach the artery
which is behind it, between the trachea or the oesophagus and the trunk of the
carotid, taking good care to avoid the recurrent nerve and the descending
branch of the great hypoglossal. As to the vertebral, that is found between the
longus colli and the anterior scalenus, outside of the jugular vein, and accom-
panied by the phrenic nerve ; it may consequently be discovered by the pro-
cess recommended by M. Sedillot for the ligature of the carotid.
Ligature of the carotid is practised, not only when it is possible to apply it
below the malady, but sometimes also according to the method of Brasdor. It
is in the latter case in fact that its advantages are more peculiarly manifest,
as will be explained in treating of the arteria innominata.
E. Innominata,
Art, 1. — Anatomical Remarks,
The brachio-cephalic trunk is about two inches in length, extending from
the anterior superior part of the aortic arch near its right extremity to the
level of the sterno-clavicular articulation, where it divides into the subclavian
and the right carotid. It affects a slightly oblique direction upwards, and
outwards and backwards. The pleura lines its external face; behind, it rests
upon the front and ri^ht side of the trachea ; and its anterior surface is crossed
at its upper part by the left subclavian vein, and lower down by the descend-
ing cava which runs in a plane parallel to it, and which removes from it by
124 NEW ELEMENTS Of
degrees as it approaches the right auricle of the heart. It is covered, besides,
only by the cellular tissue, the root of the sterno-hyoid, and sterno -thyroid
muscles, the superior and right portion of the sternum, and slightly by the
sterno-clavicular articulation of the same side.
Anomaly. — This remarkable artery presents numerous varieties ; it may be
wanting, or it may be found on the left side; it may be longer or shorter, and
may furnish at the same time the right and the left carotid, of which Walther,
Malacarne, Scarpa, and others, cite examples. It may proceed from the left
side of the aorta — cross the whole extent of the trachea, and yet be eventually
found at the right. In one instance I saw it (and my attention has been since
called to two similar cases at the practical school), passed to the left, cover
the trachea, make the circuit of that canal from front to rear, and return,
crossing between the posterior face of the oesophagus and the vertebral column,
to the level of the first rib, there to be distributed as usual.
Art. 2. — Surgical and Historical Remarks,
Aneurisms of the brachio-cephalic trunk have been very frequently observed.
Sharp, A. Burns, Messrs. Mott, Grsefe, Wardrop, Devergie, Vosseur, &c.
have made known several examples. But spontaneous aneurism, either by
dilatation or by rupture of the internal or middle coat, is nevertheless almost
the only kind to which it is subject.
A case which came under the observation of Pelletan, in wliich the subcla-
vian, the right carotid, and the extremity of the innominata, were obliterated
during ife without producing any serious inconveniences, and another of the
same kind related by Mr. W. Darrah, in which the brachio-cephalic trunk
and the left carotid were completely closed, prove that the circulation may
be maintained in the superior extremity, although the arteria innominata
may have ceased to give passage to the blood. Some surgeons therefore have
had the boldness to apply the ligature upon it for aneurisms of the neck, which
were situated too low to permit the tying of the carotid itself. Dr. Mott
practised it for the first time on the 11th May, 1818, upon a young man
twenty-seven years of age, and had at one time every reason to believe that
the operation would prove successful. The death of the patient did not take
place until the twenty -sixth day; the circulation had been re-established in
the member, and on the twentieth day the patient was so far recovered as to
be able to walk about in the court of the hospital ; but at the commencement
of the twenty-third day several hemorrhages occurred, and the patient ex-
pired in a state of extreme exhaustion. There was no inflammation either of
the aorta, the lun^s, or the pleura ; a firm and adhesive clot filled a part of
the innominata below the ligature, but an ulceration occupying the other side
of the artery had given rise to the hemorrhages. In 1822, M. Grasfe repeated
the operation of the professor; of New York ; his patient lived fifty-eight days,
and expired in consequence of having made some violent movements which
occasioned profuse hemorrhage, and perhaps, as M. Graefe himself observes,
because it had been thought best to leave a presse-artere in the wound until
that time. These two cases demonstrate that ligature of this trunk presents
some chances of success, and that it ought to be practised when the art offers
no other resources, and when the death of the ^'atient appears other vise in-
evitable. We are now happily permitted to hope, that in future the ( perator
will not be reduced to this painful alternative. Ligature between the tumor
and the branches of this artery will probably henceforth be practised, although,
out of four examples which we possess of this mode of procedure, only one
OPERATIVE SURGERY. 125
can be said to have been decidedly successful in aneurism of the trachio-
cephalic trunk itself. In following this mode it is necessary to tie at the same
time both the carotid and the subclavian ; this, however, has never yet been
done. Mr. Wardrop upon one occasion, when unable to discover any pulsa-
tion in the carotid, tied the subclanian; the tumor became much diminished in
size, but after death it was discovered that the carotid trunk was not affected.
Taken together, the cases of aneurism, whether of the innominal trunk or
of the cephalic artery, which have been subjected to the method of Brasdor,
are nine in number: three out of these were successfully treated. Two other
subjects who were believed to have been cured, eventually died. The patient
under the care of Mr. Evans ran the greatest risk. The female operated
upon by Mr. Key died the same day. It is doubtful, therefore, whether this
method will actually afford, even upon the carotids, the success which it at
first sight seems to promise. However, as it is possible that an aneurismal
tumor of the neck may be so placed as to prevent the operator from acting
upon the carotid low down, and there may be reason to believe that the arteria
innominata preserves its attributes of the normal state, I proceed to explain
the method of subjecting it to the ligature.
Art. S. — Modes of Operation.
1st. Method of Dr. Mott. — Dr. Mott made an incision of about three inches
in length above the clavicle, extending from the outer part of the sterno-mastoid
to the front of the trachea; he then made another incision of the same length
along the internal edge of the sterno-mastoid muscle, causing it to fall upon
the internal extremity of the first. He afterwards divided the whole sternal
portion and a great part of the clavicular origin of the same muscle, so as to
turn it outwards and upwards. After having pushed aside the jugular vein,
the subclavian, and some little veins and the surrounding nerves with the
handle of the scalpel, he discovered the carotid. Seeing that it appeared dis-
eased, he proceeded to the brachio-cephalic trunk, around which he passed
and tied a simple ligature of silk.
2d. M. Graefe performed the operation in a similar manner, leaving, how-
ever, an instrument in the wound, by which pressure might be suddenly applied
to the artery in case of hemorrhage. Mr. Porter, also, in 1 829, tied the carotid
in the same way, very low down ; his patient perfectly recovered.
3d. Others have been of opinion, I know not from what cause, that it would
be better to trepan the sternum ; but the best operation, that which is executed
with the greatest facility upon a dead subject, is the following, which differs
very little from that which was devised by Mr. O'Connell, of Liverpool, and
which Mr. King has described in his thesis : —
4th. The operator, placed on the left side, makes an incision in the supra
sternal hollow of the necTt, of about two inches in length, upon the internal
ed^e of the left sterno-mastoid muscle, obliquely, from the outside to the
inside, or from left to right ; divides successively the skin and the subcuta-
neous stratum, the superficial layer of the /ascia cervicalis, the adipose cellular
tissue (more abundant below than above), and a second fibrous lamina ; af-
terwards encounters, behind the sterno-thyroid muscle, the thyroideal plexus,
and, when it exists, the thyroid artery of Neubauer 5 removes, or causes to be
removed by an assistant, the last mentioned vessels, or ties them when it is
not possible to avoid them, and then arrives at the trachea. Here the left
subclavian vein and the internal jugular of the opposite side present themselves ;
these it is necessary to detach and push with caution to the right and upwards,
1^6 New elements ot
by means of the probe. The operator then slightly flexes the head of the
patient, and endeavors, by directing the fore-finger between the trachea and
the right sterno-hyoid muscle, to feel the artery ; having discovered it, he
first isolates its concavity, by passing from front to rear, between it and the
superior cava vein, with all possible care, the extremity of a probe very slightly
curved. He then passes this instrument in the same manner on the side
towards the trachea, in order to denude its posterior surface, and to raise it;
slightly augments the curvature of the probe, which serves to direct the eyed
stylet, whether directed from front to rear and from right to left, or from
rear to front and from left to right, taking care also during the whole of
tiiis procedure, to avoid tearing the pleura, touching the vagus nerve which
is left on the right, and using too roughly the subclavian vein : it would
perhaps be better, in fact, upon a living subject, to raise or depress this vein
so as to pass the sound between it and the trachea, than to withdraw it as I
have above directed. This process, undeniably more simple, more rational,
and less dangerous than any other, has also this advantage, that the same in-
cision would serve equally well for the ligature of either of the subclavian
arteries within the scalenus, and of either of the carotids at their origin.
Results of the Operation. — -After the obliteration of the brachio-cephalic trunk,
the blood is brought back by the branches of the carotids and the left subcla-
vian, which convey it into the analogous canals of the right side; afterwards
these latter, that is to say, the thyroids, the cervicals, &c., transmit it to the
supra-scapulars, the external thoracics, the acromial, the common scapular,
the circumflexes,- and so on to the whole of the superior member, which is
also additionally supplied through the medium of the intercostals and of the
internal mammary. It is not, therefore, any deficiency in the circulation that
is to be apprehended after an operation of this kind, but rather the division or
ulceration of the artery, rendered almost inevitable by the proximity of the
heart and the volume of the vessel, together wdth effusion into the pleura, and
inflaiiimation of the aorta, of the pericardium, and even of the cavities of the
heart.
Method of Brasdor. — The application of the method of Brasdor in the
neck, off*ers nothing peculiar. If the aneurism be of the cephalic artery, that
trunk is tied in the omo-hyoid triangle. If it occupy the root of the sub^
clavian it is equally requisite to tie this trunk, and necessarily on the outside
of the scalenic. Supposing the brachio-cephalic itself to be affected, the ope-
ration beyond the tumor is the only resource ; and when the malady limits
itself to the carotid, however low it may be, this operation ought to suffice.
Consequently, I see only two circumstances capable of rendering the ligature
of the brachio-cephalic trunk necessary. 1st. When an aneurismal tumor,
sufficiently developed to reach to the origin of the secondar^^ carotids, yet
leaves sufficient space above the sternum to admit of an operation, but wlien
the trunk without, being dilated, is found diseased to its origin. 2d. When,
the subclavian only being affected, the alteration of its coats is prolonged too
far towards its root to allow of its being tied, and when it is not certain that
the method of Brasdor would be successful. It is, therefore, an operation
v/hich ought seldom to be performed, and which is rarely, if ever, indispens-
able.
Aneurisms have also been seen to develop themselves upon other parts of
the body. Pelletan saw upon the summit of the shoulder a pulsatile tumor,
which he took for an aneurism of the acromial artery. Ruysch and A. Petit,
Weltin and M. Briot, saw each an example on the chest, in the passage of
the intercostals. Thinking to open an abscess, Desault plunged his bistoury
OPERATIVE SURGERY. 127
mto an aneurism of one of the thoracic arteries, and M. Floret, in his thesis,
speaks of a case in which the first four intercostals offered, from space to space,
a great number of true aneurisms. Supposing these facts not to belong to
other maladies, they are involved in what has been already said of the axillary
artery, and in the discussion of the ligature of the intercostal artery, which will
be taken up under the article empyema*
CHAPTER III.
NiEVI MATERNI.
Erectile Tumors. — Left to themselves, the sanguineous tumors, which have
their origin in a connatural blemish, and the nature of which modern practi-
tioners have caused to be better understood than formerly, sometimes acquire
considerable volume. Lassus met with one which was as large as the head
of an adult, and M. Latta extirpated another which did not weigh less than
fourteen ounces, although it occurred upon an infant of two years. As the
organization is not able to effect the removal of these aneurisms, prudence
dictates that they should never be neglected when they begin to increase with
any degree of rapidity, or when they have already attained a considerable
size. The same remarks apply to accidental erectile tumors of every species,
which have their seat either in the venous or arterial system, and which may
manifest themselves at any period of life.
1st. Astringent Remedies^ styptics, or refrigerants, although frequently
employed by the ancients, and recommended by Abernethy, who by these
means in the course of some months caused the disappearance of an erectile
tumor of the orbit, are yet seldom alone found sufficient, and ought never to be
tried but in cases where the tumor is too small to excite much apprehension.
2d. Compression. — Although it is not a resource upon which the operator can
place much reliance, compression has jet succeeded often enough to justify
its use whenever the volume and situation of the tumor permit. Batteman, it
is true, speaks unfavorably of it, and says that it exasperates the malady;
but it has been used with incontestable success by Burns, Abernethy, and Mr.
Randolph. M. Roux cured one of his children by these means, and M. Boyer,
who hardly dared to recommend it, cites a case of naevus of the lip cured
by the tenderness of the mother, who had the constancy to press her finger
seven or ei^ht hours a day for several months below the nose and across the
lip of her cnild. In the case of a child a few months old, troubled with a
small erectile tumor in front of the breast, M. Roux, after having renounced
compression, saw the swelling decrease and eventually disappear. Styptics
and astringents may be also very advantageously associated with compres-
sion.
3d. Caustics. — Caustic plasters, or simple escharotics, vaunted by Callisen,
Wardrop, &c. ; nitric acid, still used in England; nitrate of silver, recom-
mended by Mr. Guthrie when the najvus is small or not very thick ; and the
multiplied vaccine punctures praised by M. Cumin, are^evidently insufficient,
1^8 NEW ELEMENTS OF
except in a very limited number of cases. The hot iron which was success-
fully used by M. Maunoir, and all active caustics, when they do not com-
pletely extirpate the evil, are sometimes attended v/ith the most serious
consequences, such as consecutive hemorrhage, and acceleration of the
progress of the tumor. The loss of substance, the suffering, and the deformed
cicatrices which follow the employment of these means, are enough in feet
to prevent every prudent and humane practitioner from having recourse to
such means when any other aflford a chance of relief.
4th. Ligature of the Tumor. — It is not so with the ligature, which may
be employed in several different ways. In one, that of Mr. White, the
operator draws the tumor towards himself with one hand in order to re-
move it from the subjacent tissues, while with the other,^he passes a needle
with a double thread through the skin behind the fungus, which latter may
afterwards be easily compressed or strand-ed by bringing the extremities of
the ligatures together, and tying them, nie one above and the other ])elow.
Mr. Itawrence, who is from experience opposed to cauterization, has pub-
lished three observations, sufficiently conclusive, in favor of the practice of
Mr. White, which practice has also been adopted by Messrs, Lyne, Carlisle,
Guthrie, and for a long time, says the latter, by the surgeons of the Westmin-
ster Hospital, Bv another mode of operation no tissue is pierced, but the
operatorcontentshimself with embracing circularly and with a strong ligature
the base of the naevus. This method is not confined to pediculated tumors..
M. Gensoul, of Lyons, according to M. Penod, still uses it with success
whenever the base of the tumor is not immoderately large, and the skin which
surrounds it is sufficiently flexible and movable to yield without difficulty
to the action of the ligature. But there are many cases in which tlie ligature
is totally inapplicable by either method. Finally, Mr. Keate, and after him
Messrs. Lawrence and Brodie, adopted a third mode of procedure, which
consists in passing a single straight needle, if the ncevus is small, or two needles
crossed under the tumor if it is large ; the tissues are afterwards strangulated
by mean? of a circular ligature, sufficiently tight, placed between the needles
and the healthy skin.
6th. Ligature of the Arteries. — Comparing erectile tumors to aneurisms, it
was natural to seek a cure by ligature of the arteries upon which they were
seated. Pelletan was the first to try this method in a case of varicose tumor^
which occupied the lateral and rather posterior part of the cranium; he was
not able however to discover the occipital, and his operation was consequently
incomplete. I have already stated that Messrs. Travers, Dalrymple, and
Arendt, each cured an erectile tumor of the eye by tying the carotid of the
same side, and that Dr. Pattison was equally successful in the case of a young
man affected with a similar malady behind the cheek. M. Roux also derived
some advantage from tying one of the facial arteries for a fungus of the lips.
Other practitioners, on the contrary, have been completely unsuccessful in
their operations by this method. Hodgson was unable, even by tying both ar-
teries of the fore-arm, to arrest the progress of a tumor of this kind upon the
thumb. It was in vain also that M. Dupuytren tied the carotid for an erec-
tile mass of the concha of the right ear. For some days appearances pro-
mised success ; but the tumor soon returned to its former state. It would be
wrong therefore to consider this method as an unfailing resource.
6th. Okcular incision of the base of the tumor. — Dr. Physick adopted a dif-
ferent process, and in some cases followed it with complete success. Instead
of successively exposing all the arterial branches which supply an erectil«
tumor, he made an incision round the base or root, and thus in some degree
aPERAxfVE SURaERY/ 129
isolated it from the living tissues and the canal, which supplied it with the
fluids. By imitating this method, Mr. Lawrence cured the sanguine tumor
of the thumb, which has been mentioned as resisting the efforts of Mr. Hodg-
son. In following this mode of treatment it is necessary that the incision be
made upon healthy tissues, and that it should comprehend the whole thickness
of the skin, the cellular stratum, the arteries, and the veins, without being ar-
rested by the nervous twigs, unless they have some important duty to fulfil, in
the part. Each arterial branch is tied as it is divided ; and to prevent immediate
reunion, lint or small pieces of linen are placed between the lips of the wound.
6th. Extirpati&n is unquestionably the most efficacious resource, but it can-
not be always called in. It is practised in three different ways: 1st. By
conforming to the rules laid down for the extirpation of all other kinds of
tumor. 2d. By removing at the same time the morbid tumor and the part
which supports it. 3d. At two, three, or a greater number of operations.
The first method, which is most generally adopted, which is so strenuously
insisted upon by J. L. Petit, and which Messrs. J. Bell, Wardrop, Boyer,
Roux, Dupuytren, Maunoir, and Dorsey, follow from preference, requires that
the operator should encroach a little upon the healthy parts, if he would pre-
vent the reproduction of the malady. In order as much as possible to avoid
hemorrhage, the arteries should be carefully tied as they are opened during
the operation; by neglecting this precaution, or availing himself of it too tar-
dily, Mr. Wardrop had the misfortune to see an infant expire under his bands.
A little girl also, operated upon by M. Roux, fell immediately afterwards into
a syncope which lasted four hours. The second mode of extirpation never
is and never ought to be employed, excepting when it is impossible to make
use of the others, or when the tumor is seated upon a small and unimportant
part of the body, a finger or toe for example. The merit of the third,
described in the work of Dr. Dorsey, is due to Professor Gibson, of Philadel-
phia. Fearing the loss of too much blood in the case of a woman aged
twenty-five, and in whose person almost the whole of the right side of the
head was involved in the disease, this gentleman resolved upon performing
the operation at three several times. On the first occasion he incised exactly
a third of the tumor, promptly secured the vessels, and kept the wound open.
At the expiration of a few days, a second incision, made with the same pre-
cautions as the first, circumscribed another third of the fungous mass, and a
week afterwards the extirpation of the whole was effected. The patient found
herself completely recovered at the end of thirteen or fourteen days.
CHAPTER IV.
OF VARIX.
Historical. — Although varices do not constitute a malady essentially dan
gerous, they are yet sufficiently so to demand the aid of surgery. The pain,
the deformity, and the ulcers which they cause or maintain, together with
17
130 NEW ELEMftNTg OF
the hemorrhages which they sometimes originate, sufficiently explain the soli-
citude of which they have always been the subject. The ancients, who em-
ployed against them topical remedies, astringents, desiccatives, and resolv-
ents, used also the compressive bandage, which they applied upon the whole
extent of the member, pretending also to forward its action by means of in^
ternal medications. Then^ as now, those different modes of treatment were
mereljr palliatives. To obtain a radical cure it was necessary to perform an
operation. Sometimes, however, they contented themselves, like Hippocrates,
and as it was recommended even by Pare and Dionis, with puncturing the
varix, and incising it length-wise (more extensively than in phlebotomy), in
order to empty it of the fluid and coagulated blood. According to Avicenna,
the vein should be taken up with hooks upon two points distant, three fingers'
breadth from each other, then tied with a good silk thread, and cut across in
the interval ; after which the ligature should be removed from the inferior
end, and the blood forced out as much as possible with the hand : the superior
extremity of the vessel, and the whole extent of the wound is then cauterized
with arsenics or a red hot iron.
Albucasis recommends that a bandage should be placed upon the thigh
as far as the knee, and that the vein should be opened and cut in two or three
places, in order that as much blood may be forced out as possible.
Others extirpated the varices after having incised them ; this mode of pro-
cedure, at least, seems to have been counselled by Ali Abbas. Celsus speaks
of cauterization and extirpation ; and every one who has read Plutarch, knows
that the stoic Marius, who had been treated in this way, after having been
relieved of varices which had covered the whole of one leg, refused to present
the other to the surgeon, which was in the same condition, saying that the
remedy was worse than the disease. Dionis is astonished tliat the ancients did
not make use of the heated iron to extirpate varicose veins, as upon horses, and
that they should have contented themselves with the potential cautery. Ac-
cording to this author, the rolled bandage applied in the form of buskins is
preferable to all other means. It was also the advice of a great many surgeons
of our own day, when an attempt was made some years ago to simplify the
operations of the Greeks and Arabs.
1st. Excision is rarely necessary, and ought never to be practised, as has been
justly remarked by Boyer, excepting in cases of those large tumors or varicose
lumps which are sometimes seen on the leg, and even then it is not certain,
that it might not be beneficially replaced by other and simpler means.
2d. Ligature, so clearly and carefully described by Dionis, has been frequent
Ij^' practised by Sir Ev. Home, in England, and by Beclard, in France. A lon-
gitudinal fold, says M. Briquet, who reports the results obtained by Beclard,
IS made in the skin, and divided to its base upon a point of the member where
the vein is single and most superficial. The operator then passes beneath
the vein a needle stylet carrying a thread, and after having tied the ligature
divides the vessel immediately above. He may also divide the skin and the
vein at a single stroke, and afterwards tie the inferior extremity of the venous
canal, by seizing it with pincers. The lips of the wound are closed by means
of bands or fillets, and the patient should be kept in a state of perfect rest.
Messrs. Smith, Travers, and Oulknow, have imitated the treatment of Mr.
Home, but not with such constant success. Dr. Physick is said to have had
reason to praise it, and Dr. Dorsey, by whom it was frequently tried, aflirms
that he never saw it produce any serious or dangerous results. Out of sixty
operations performed by Beclard, at La Pitie, only two, says M. Briquet,
were attended with a single unfavorable symptom. It is diflicult, in fact, to
OPERATIVE SURGERt. 131
comprehend how this ligature, properly applied, can be attended with great
pain, and followed, as has been pretended, by tetanus; or why inflammation of
the vein towards the heart should be produced by this any more than by any
other method which requires the obliteration of the vessel. The process of
M. Gagneles, cited by M. Marchal, and which consists in passing a ligature
round the vein by a simple puncture of the skin, would only render the ope-
ration more difficult without avoiding any thing that could be apprehended.
3d. Incision. — Not wishing to confine himself to simple incision, M. Riche-
rand thought that by incising parallel with the member, and to a great extent
the tortuosities or varicose knots, he should more certainly succeed. I have
seen this method followed several times at St. Louis's hospital with perfect
success, and I have myself applied it with advantage on different occasions j
but the only patient upon whom I practised it at La Pitie, died on the
ninth day. The operator should choose that part of the member where the
varices are most numerous, and should incise them deeply, and to the extent
of four, five, six, and even eight inches. After having forced out the clotted
blood by pressure, he should fill the wound with lint smeared with cerate.
The first dressing takes place at the expiration of three or four days. After
that time the venous orifices are closed, and the wound may be smoothly
dressed, like all other simple solutions of continuit3^ Beclard practised this
method upon some occasions, and as successfully as M. Richerand. These
long incisions, however, create great alarm in the mind of the patient, and
upon mature reflection there appears to be little necessity for them.
4th. Would not the division of a single and selected point, or of different
branches, when it is not desirable to act upon the principal trunk of the vein,
be evidently preferable. I have practised it thirty-seven times at the hospital
St. Antoine, and at La Pitie. One of the patients it is true died on the
twelfth day, but he evinced the most extraordinary ataxic symptoms, which
could only be attributed to the state of fear and inconceivable moral con-
straint to which he had brought himself before the operation. We did not
meet with any traces of phlebitis above the wound, aiid that which existed
below bore no proportion to the progress of the fatal symptoms. Nothing can
be more simple than such an operation. The vein is at first taken up in a
fold of the skin, and a straight bistoury, very sharp, passed across the base
of this fold then divides it at a single stroke. The operator thus successively
incises (when it is not thought necessary to divide the trunk of the saphena
itself near the knee) all those veins which are at all voluminous, and which
seem to take their root in the middle of every knot of varices. The blood
immediately issues in abundance, and is suffered to flow for a longer or
shorter time, according to the strength of the patient, after which the wound
is filled with balls of lint, and covered with a cerated pledget, and with soft
and flexible compresses. The whole oudit afterwards to be kept in place by
a rolled bandage moderately tight. If immediate union should take place,
the continuity of the vein might re-establish itself, and thus cause the failure
of the operation.
Hoping to avoid phlebitis with greater certainty, Mr. Brodie contented him-
self with dividing the veins transversely, making only a simple puncture
through the skin. He used a bistoury with a narrow blade, and a little con-
cave on its edge. The point of the instrument is at first passed through the
integuments on one side of the vein ; it is then directed flatly between that
vessel and the skin ; and when it reaches the opposite side the edge is turned
backward and the wrist of the operator is raised in such a way as in drawing
back the bistoury completely to divide the vein. Mr. Carmichael and other
132 NEW ELEMENTS OF
practitioners, have highly praised this process; a patient, also treated in this
way in my presence by M. Bougon, found himself perfectly relieved ; but
Beclard, who practised it at La Pitie, says that it does not offer any greater
security against phlebitis or phlegmonous erysipelas than the ordinary incision,
and besides, that it sometimes fails to obliterate the vein.
5th. Resection^ which was practised so early as the times of Ali Abbas,
Avicenna, Albu-Kasem, &c. have given to M. Lisfranc more satisfactory
results than the simple incision. By retracting under the lips of the wound,
the two extremities of the vein immediately cease to be subject to the influ-
ence of the external air, the action of which, according to Mr. Brodie and
Lisfranc, is a powerful cause of phlebitis.
Comparison. — To obliterate veins which have become varicose, is the avowed
and incontestable aim of the operator; yet it cannot be denied that the liga-
ture, with or without division, the section transverse or longitudinal, exposed
or under the skin, that even extirpation itself, as well as cauterization with
potash or the red hot iron, are insufficient to effect this result.
It only remains, therefore, to decide which of these means may be most
easily executed, involves the least danger, and causes the least pain. In my
opinion the transverse incision of the vein comprehending the skin, promises
all the advantages of the other modes, together with all desirable simplicity.
It is performed in the twinkling of an eye ; the youngest student may per-
form it with ease ; the pain is trifling, and the whole operation differs very
little from an ordinary bleeding. The ligature, so much vaunted by Hone
and Beclard, is only calculated to render the operation more difficult and
dangerous. And why should the practitioner expose himself, by imitating
Mr. Brodie, to the probability of leaving the vein partially divided, and
seeing the blood effused into the subcutaneous stratum, forming the point of
departure, the nucleus of a phlegmon or an abscess ? Ought the division of the
skin ever to cause uneasiness after such an operation ? And who does not now
know, that the action of the air upon the veins is incapable of producing any
of those terrible effects which have been so gratuitously ascribed to it? As
to the long and deep incisions recommended by M. Richerand and formerly
by J. L. Petit, and the excision of Celsus as practised by M. Boyer, they
ought not to be thought of, excepting in cases where varices form painful
masses, and have degenerated into tumors which will yield to nothing but
extirpation.
But after all, is it right to resort to the most easy and least painful of
these operations ? Does not humanity revolt at the idea of phlegmons, ery-
sipelas, purulent collections, phlebitis, and all the other accidents which
have more than once resulted from them, in cases where the varices did not
at all endanger the lives of the patient? Why should not the operator con-
tent himself with a laced stocking or rolled bandage, which would maintain
the parts in a proper position without any risk to the patient? These objec-
tions appear to me more specious than solid. It is not perfectly correct to
say that varices are unattended with danger. Chaussier cites an example of
a ruptured varicose vein in the case of a pregnant female, which quickly
produced death. Similar instances have been mentioned by Murat, Gri-
maud, Amussat, Rees, La Croix and Lebrun; and one case fell under my
own observation. The death of Copernicus is attributed to such an accident.
The bandages or gaiters which are so earnestly recommended, require care
and precaution in their use, and often cause excoriations upon different points
of the member, so that they are not entirely without their inconveniences.
Finally, those ulcers which it is so difficult to cure, and which almost always
OPERATIVE SURGERY. 133
return when the patients make the least eieertion — which are the despair of
the surgeon and the misery of those who are so unfortunate as to be afflicted
with them*^will any one say that they never produce death, that they are
never the cause of any serious maladies, and that they never make it neces-
sary to amputate the limb ?
On the other side, if it be true that after the incision of the veins phlegmo-
nous inflammations and engorgements of various kinds sometimes take place,
that even phlebitis may manifest itself, it is not less true that all these ac-
cidents are very rare, that they are generally easily remedied, and that above
all, they may be almost always prevented, if, after a simple incision such as
I have (described, the operator takes the precaution, when there is reason to
fear inflammation, to envelop the member from its extremity to its root with
a compressive bandage. It should always be remembered, however, that
these operations cannot be counted upon as infallible, and that they ought not
to be practised excepting in cases where the deep-seated veins are in their
natural state, at the demand of the patient, and when the varices have proved
capable of impeding the functions of the injured part, or of compromising the
general health.
TITLE II.— OF AMPUTATIONS.
CHAPTER I.
AMPUTATIONS IN GENERAL.
Amputation, the last resource and extreme eflTort of surgery, ought never
to be practised but in despair of other remedies. It is of a doubly serious
nature, inasmuch as it endangers life and mutilates the body. Even when
amputation seems necessary, the skillful practitioner will never forget that
the end of surgery is to preserve, not to destroy ; and that he will be entitled
to greater credit for preserving one limb, than he would for making with all
imaginable address a great number of amputations : on the other hand, it is
better to sacrifice one part than to lose the whole — to live with three mem-
bet;s, than to die with four.
The painful necessity of cutting away the whole or a portion of one" of the ap-
pendages of the trunk, has been felt and acknowledged from the earliest years
of surgical experience., The mortification and natural and accidental dropping
off of the members, which must have been observed among the ancients, as well
as among ourselves, doubtless suggested the first idea of amputation. It was
rarely, however, that they decided upon its execution. The Hippocratists
give very few details upon this subject. Galen himself, elsewhere so prolix,
scarcely mentions it, and it is not until we come to Celsus that we find a
description of the operation somewhat more at length. This negligence on
the part of the ancient authors, is, however, easy to be understood. Know-
ing little of the circulation of the blood, they were unable to guard against he-»
*1S4 NEW ELEMENTS OF
morrhages, and were constantly impeded by their fear that death would result
from the cutting away of a living portion of the body. Again, before the dis-
covery of gunpowder, wars were less murderous in their nature, and rendered
amputation also less frequently indispensable.
In the beginning they were obliged to content themselves, as is recom-
mended by Paulus jEgineta, with cutting off' the dead parts without touching
the living tissues, and this practice, which was continued by the surgeons of
the middle age, is still recommended by Fabricius de Aquapendente. Although
the old surgeons scarcely speak of amputation excepting in cases of gangrene
or erosive ulcers, it is nevertheless certain that they early admitted the ne-
cessity of dividing the tissues above the mortified parts. Celsus fomaally
prescribes it, and Achigenes, of Apamea, appears frequently to have executed
it. Always terrified at the hemorrhages which ensued, they imagined a thou-
sand means (now forgotten) of preventing it, and the operation became
eventually so terrible to them, that many, rather than practise it, preferred
leaving the patient to certain death. In performing amputation, some com-
menced by tying the vessels by means of a ligature passed through the whole
thickness of the limb, or by compressing the limb itself, and afterwards
sprinkling it with cold water. The operation being terminated, the surface
of the stump was burnt with a red-hot iron. Others, after the manner of Al-
bucasis, incised the soft part with a knife heated to whiteness, and afterwards
cauterized with boiling oil. This latter author, less timid than is generally
believed, says : *' When it is not possible to preserve the limb, it should be
cut away up to the healthy part, since the loss of one member is better than
the death of the whole body." Avicenna, according to the celebrated Guy,
recommends that amputation should be performed a little above the diseased
tissues, ** at the place to which hardness and pain are discovered on the in-
troduction of the tent." In practising this operation, the member is at first
firmly held by the assistants ; the soft parts are then divided to the bone with
a razor, and the surface of the wound is covered with a compress in order
that it may not be lacerated by the saw; the surface of the stump is after-
wards cauterized with a hot iron or boiling oil. *' As to myself," says Guy,
of Chauliac, " I envelope the whole of the mortified member in a plaster, and
suffer it to remain in this state until it falls of itself. This is more honor-
able to the surgeon than amputation ; for if the limb be taken off", tliere always
rankles in the heart of the patient a belief that it might perhaps, have been
preserved." In despite the efforts of Pare to introduce the practice of tying
the vessels after amputation, Pisray, Dionis, and Rossi, still preferred the ac-
tual cautery. But surgery has long since done justice to this barbarous prac-
tice. It appears that from the time of Hippocrates and Galen amputation
was admitted as a surgical resource, although Heliodorus, who lived between
those two authors, endeavored to proscribe it.
Amputation was also practised by the Arabs ; for it is said in their books,
that if the corruption extends to the joint, it will be necessary to cut into the
articulation itself with the razor or other instmments, without using the saw.
The method of Celsus, although defended by Gersdorf of Strasbourg, by
Cervia a long time before, by Maggi and some others afterwards, was, not-
withstanding, abandoned by the greater part of practitioners ; so that in the
seventeenth century Botal was not ashamed to perform amputation by means
of two hatchets, one placed immediately below the member and the other,
loadeil with lead, let fall upon it. Finally, from the time of Ambrose Pare
and Wiseman, the mode of practice became materially changed, and the ope-
^ -ration is now performed witli much less danger.
OPERATIVE SURGERY. 135
SECTION I.
INDICATIONS.
Cases which require amputation merit particular attention, and will become
it is to be hoped, less and less numerous as medical knowledge advances, and
as the just treatment of diseases comes to be more generally understood.
Art. 1. — Gangrene,
Mortification.^— The only circumstance which was formerly supposed to jus-
tify the amputation of a limb, is not now the cause whicli most frequently
renders the operation requisite, although it must be confessed that it forms
one of the most positive indications. Amputation in this case is only warranted
when the mortification has invaded the whole thickness of the part, or at
least when it is sufficiently deep to leave no hope of preserving its principal
elements. With regard to amputation, gangrene involves a question which
some moderns have attempted to solve differently from the ancients. Pott,
and before him, Sharp, strenuously maintained the necessity of waiting until
the organization had arrested the progress of mortification and established its
limits, before thinking of amputation ; without attention to this particular say
they (and the majority of surgeons agree with them in opinion), the mortifi-
cation will affect the stump, continue to propagate itself in the direction of
the trunk, and will only be aiTCsted by the death of the patient, while the
surgeon will have performed to no purpose a most painful operation. This
manner of viewing the matter, founded upon an exact observation of facts,
ought to be adopted as a general but not as an absolute rule. Messrs. Larrey,
Yvan, Lawrence, Dupuytren, Gouraud, Guthrie, and Chaussier, who, while
justifying the conduct of M. Labesse of Nancy, in a case of this kind have
admirably established the distinction necessary to be made. Messrs. Mac-
dermott and Busch, who have recently reported several observations on this
point, and many other modern surgeons, have proved that it is sometimes pru-
dent to pursue an opposite course of conduct, and to practice amputation
before the gangrene has become limited. For example, when a traumatic
injury is the cause of mortification ; when it proceeds from the rupture of an
artery or the division of the vein or principal nerves of the member, or from
the mechanical compression of the part ; when in fact it does not seem to result
from a constitutional affection, from any external or hidden cause ; it is diffi-
cult to see what real advantages can result from temporizing. Gangrene ought
here to be considered as a cause of gangrene, and as soon as that is well esta-
blished the patient cannot but be a gainer in being relieved as speedily as pos-
sible from the presence of the mortified parts.
If gangrene on the contrary, proceeds from the spontaneous obliteration of
the artery or principal vein of the member, as is frequently the case, then,
indeed, it is evident that amputation will not prevent it from spreading. The
success of the operation would then still be a matter of chance. The object
of the practitioner might be accomplished if the knife fell above the oblite-
rated part, but the reverse would be the case if it did not. In such a con-
juncture, prudence requires one to pause. So that senile gangrene, which
comes under this head, will not, even if the general state of the patient do not
exclude the idea of amputation, permit us to resort to it until the disease have
156 NEW ELEMENTS OF
paused in its ravRges, and its limits have been marked by an inflammatory
fine. The point, then, is to distinguish these two cases from each other.
Art. 9>.^—Fructures,
Complicated fracture is . one of the causes which most frequently render
amputation necessary. But to do this it is necessary that the fracture have
been attended with serious injury of the soft parts. When the artery, the
vein, or the principal nerves remain unbroken; when the muscles preserve a
partial continuity ; when, in short, gangrene does not appear inevitable, it is
always prudent to wait a little and to try in every way to obtain a cure with-
out mutilating the patient. If fragments of bone or splinters, are free or buried
in the flesh, they are to be extracted ; but if the extremities of either portion
of the fractured bone appear without and cannot be reduced by deep incisions
t)r other justifiable means, it is thought good to remove them with the saw.
Even when the muscles are so bruised as to be reduced to a sort of jelly, it
does not follow (if any of them remain entire, and there is a possibility of the
circulation of the fluids below the fracture), particularly if the thoracic limb
is concerned, that the member should of course be sacrificed. Three male
adults who had experienced fractures of this nature in the leg, were cured
witliout amputation at the hospital of St. Anthony, in 1829 and 1830, although
two of them, becoming suddenly delirious on the sixteenth or eighteenth day,
got up with their dressings on, and walked about the hall of the hospital. I
saw at VHopital de Perfectionnement, a case in which all the muscles of the
internal and anterior region of the fore-arm had been lacerated and beaten
almost to a jelly by a spinning machine. The skin was also injured, and the
radius and ulna fractured in two or three places. The patient, a young man,
having several times refused amputation, eventually recovered without an
operation and preserved the limb. In civil practice the surgeon should never
lose sight of the following remark, viz : that with care, proper regimen, and
all the resources of a scientific treatment, it should be rare to find complicated
fractures immediately demand amputation. It is, however, sometimes indis-
pensable, particularly when the fracture reaches so far as the next articula-
tion. Out of three subjects who presented themselves in this state, at St.
Anthony's hospital, and whose legs I tried to preserve, two died in a few days,
and the life of the third was only preserved by amputation, which was prac-
tised on the fourteenth day in consequence of gangrene. It is true that a
iburth upon whom the operation had been performed immediately, died, not-
withstanding, on the seventh day ; but in that case the sources of vitality were
«o nearly dried up at the time of the operation that the patient scarcely knew
what was done to him. To the numerous facts brought forward by M. Bardy
in 1803, for the purpose of demonstrating that in these cases removal of the
limb is scarcely ever necessary, M. Bintot has opposed others not less conclu-
sive, in support of the contrary opinion.
Art* 3. — Lutations.
Luxations with laceration of the soft parts are sometimes followed by symp-
toms so formidable, so torrifying, that they were at an early period classed
with those cases which most imperiously call for amputetion. The opinion
expressed by a military surgeon, and which made so lively an impression
upon tlie mind of J. L. Petit, viz. that all luxations of the foot, with laceration
of the integuments and cutting out of the bone, would prove mortal, unless
OPERATIVE SURGERY. 137
amputation were immediately practised, has been but too often verified. The
dreadful pain which follows their inflammation; the gangrene which fre-
quently results from them, and which nothing can arrest ; and death, pre-
ceded by the most lively agonies, which alone seems capable of terminating
so many evils, appear sufficient to justify the surgical rule established upon
this subject.
Yet experience has proved that there may be many exceptions to this rule ;
J. L. Petit himself has been very careful to remark this, and M. Laugier, M.
Arnel, &c., have very recently given new proofs of the fact. If the laceration
is not very extensive, if the bones are simply luxed without being broken, if
the nerves and principal vessels are not divided, and if gangrene does not
appear inevitable, the surgeon should replace the parts, have recourse imme-
diately to scarifications, antiphlogistics, and anodynes of every kind ; should
combat w'ith energy any unexpected or unpleasant symptoms which may make
their appearance, and should never resort immediately to amputation, unless
the integuments, tendons, ligaments, and articular capsules are extensively
lacerated, the bones and soft parts torn and violently contused, or the joint
too complicated or too unimportant to justify an attempt at its preservation.
By proceeding thus, some patients whose lives might have been saved by am-
putation, will perhaps be lost, but a far greater number will be curea, and
preserve their limbs.
Art, 4. — Caries, Necrosis.
The last remedy of caries and necrosis, whether of the middle part or of
the articular extremities of the bones, is also amputation. To justify its use,
however, the disease should be extensive ; have existed for a considerable
time ; have caused great suffering or an exhausting suppuration ; should
occupy an articulation and an extended surface, or be surrounded by fistu-
lous ulcers and deep degeneration of the soft parts ; the bone should be
affected throughout its whole thickness, if in the continuity of tlie limbs ; and
reproduction through the vessels of the periosteum cannot be counted on. It
should also in such cases be remembered that the organization is very pow-
erful, and that the surgical art actually possesses the means of partially
removing the bone without removing the limb, when the soft parts are in a
staCe to be preserved.
Art. 5. — Cancerous Affections.
Spina vcntosa, osteosarcoma, the colloid, hydatoid, and erectile degenera-
tions, give less latitude, and demand much more positively a resort to ampu-
tation. These affections are of so malignant a character, that the practitioner,
even of the present day, may consider himself fortunate if he is able to destroy
them finally by sacrificing the part upon which they are situated. Unless
they occupy a very superficial, long, and slender bone, it is wrong to hesitate
an instant. However little the soft parts may participate in the disease, am-
putation cannot be dispensed with. The same observation applies to the
fungus hematodes, from the moment that it becomes impossible wholly to
extirpate it without affecting the continuity of the bone or bones of some im-
portant parts of the limb. M. Hervez, of Chegoin, has perfectly established
the point, that extirpation or amputation, when practicable, is the only effica-
cious remedy for sanguineous fungous tumors, with a mixed mass of hetero-
geneous tissues, brainiike matter for instance, as soon as they have invaded to
18
If^S NEW ELEMENTS OF
a certain extent the thickness of the organ. But we should be cautious not
to confound the above with simple erectile tumofs, which at the present day
are often cured by gentler and less painful metliods. As to cancers, properly
so called, there is no necessity for waiting until they penetrate to the bone
before amputating. If they are large, immovable, and extend beyond the
integuments, comprising the aponeurosis, the muscles, and the vessels or the
nerves, the safety of the patient would be compromised by any attempt to pre-
serve the limb.
Art. 6. — Aneurisms.
For the cure of aneurisms and simple wounds of the great vessels, other
and more simple means are now adopted. The ideas of Petit and Pott upon
this subject are rarely applicable at the present day, and can only be adopted
in cases where gangrene threatens, or already exists; when the aneurism is
too voluminous, and the surrounding parts too deeply affected for the ligature
to afford the least probability of success ; or when, after the ligature, second-
ary hemorrhages, caused by the ossification of the artery or by mortificatioii,
unexpectedly ensue ; when the principal nervous trunks are divided, or the
vein has been enclosed in the same ligature with the artery ; when the muscles
have been reduced to a soft mass, or become disorganized in any way what-
ever ; or when the neighboring bones are themselves affected, have become
brittle, or are to a greater or less extent destroyed.
When a coach-wheel, a machine^ or any exterior agent whatever, has
effected amputation, either by tearing away the part or in any other manner,
the member, being in the same state as after gangrene, requires amputation
above the accidental division as much as if it had suffered nothing but attri-
tion and contusion of the tissues.
Art. 7. — Suppurations.
Suppurations, either of recent or of long standing, superficial or profound,
however large, seldom absolutely require amputation, unless they have their
origin in a disease of the bones. Regimen, a skillful application of medi-
cines, incisions, and convenient dressings, should generally suffice in the early
stages of the disease. Otherwise, the cause should be sought in the general
state of the patient, or may be traced to some internal affection, and then
amputation would only tend to hasten the progress of the evil. It is impos-
sible to shut the eyes against the danger to which the patient is exposed by
those suppurations whicu sometimes invade the greater part of a limb, and
which are commonly the result of an inflammation of the synovial and tendi-
nous laminae, of the intermuscular cellular tissue, &c. As these dangers,
however, do not always exist ; as death is not always the inevitable result ; as
it is possible to combat them advantageously, or what is better still, in a great
number of cases to prevent thejn ; the suppuration of the parts, without alter-
ation of the bones, ought not to be classed among those cases which reqiure
amputation. The only patients (three in number) who ever suffered ampu-
tation in my prcseiace, died as soon as if the operation had not been performed
upon them. In the case of the first two a suppuration, which the most nume-
rous incisions had not been able to arrest, occupied the whole of the fore-
arm ; in that of the other, the malady approached the wrist and extended
nearly to the elbow : all three lost their arms and died before the fifteenth
4ay, having purulent depots in the bowels.
OPERATIVE SURGERY. ISS
These remarks apply also to exostosis, and to fibrous or other tumors ; unless
they are very voluminous, compromise the general health, or destroy the
nat-uralitises of the parts, and absolutely cannot be separately removed or de-
tached from the bones, or the neighboring organs most essential to the main-
tenance of life in the rest of the limbs.
Art. S. — White Swellings.
The numerous observations published of late years by Messrs. Larrey,
Brodie, and Lisfranc, prove that white tumors will also yield more readily
than is generally supposed to the rational use, therapeutic means, and that it
would be unworthy an honest man to amputate the affected member, until the
caries or suppuration of the articular surfaces became evident, and before
having exhausted every resource that prudence permits to be employed. If
tlie capsule on the contrary has been long filled with pus, if there be fistu-
lous sores about the joints and rubbing over the parts, or the introduction of
the probe leaves no doubt as to the extent of the caries or the necrosis ; if
the ligaments and the surrounding fibrous strata are destroyed ; if an ichorous
and abundant liquid escapes from them ; if the fungous or fatty alteration has
seized upon the synovial membrane and the soft parts generally ; if the
member is in a state of atrophy above and below, is luxed or has a tendency
to become so ; if, in a word, it is demonstrated that the bones or cartilages
liave been for a long time the seat of a deep morbid action, the necessity of
amputation may then be said to be formally indicated.
Art. 9. — Tetanus, Bites of Rabid Animals.
Erosive ulcers of the legs, which formerly were considered as particularly
demanding amputation, do not really require it, and can only justify its use in
very few cases: when, for example, the skin is destroyed, or the muscles
separated round the greater part of the limb ; and even in these cases, the
consent of the patient should be obtained, and he should be convinced, before
submitting to the operation, that there is no possibility by any other means of
effecting a cure. Did M. Larrey, M. del Signore, and some others, derive any
benefit from the amputations which they had the courage to practice in certain
cav<?e3 of tetanus ? were not those cases on the contrary rather aggravated than
relieved by the removal of a limb ? I remember, it is true, the case of a coun-
tryman whose life was thus saved some years ago by M. Dubois, and I am
aware that our medical annals present here and there some instances of success
obtained by the same means : but two of the patients upon whom M. Larrey
operated died notwithstanding the amputation, and the case of the third was
such as to leave great doubt in the mind as to the real nature of the disease
with which he was affected. If the wound itself which has occasioned tetanus
is of sufficient importance to justify an extreme resource, the appearance of
sucli a frightful event may certainly be permitted to have some weight as a
determining motive. There is less room for hesitation too when the part is
of small importance ; but in other cases I am so much the less disposed to follow
the practice of our celebrated military surgeon, as amputation is well known
to be a powerful cause of the very evil v/hich it is here intended to cure. The
bite of rabid animals is also by some practitioners considered a sufficient cause
for amputation. Very recently, at a London hospital, Mr. Calloway did not
hesitate to amputate the arm of an individual who had been bitten in the
hand; and who (by way of parenthesis) died shortly afterwards of hydro-
140 NEW ELEMENTS OF
phobia. What could such an operation'effect against an infection already dis-
seminated, against symptoms wiiich evidently have their immediate source in
the intestines, or some general organic system, which, in a word, are alto-
gether independent of the primary injury ? At the most, amputation can only
be permitted when a part like a finger has beeii bitten, unless the wound is
so extensive, complicated, or deep, as to forbid cauterization, or prevent a
thorough removal of the sides of the wound. But even then, amputation
should be immediate; for when once an absorption of the virus has taken
place, what can we hope from amputation ?
Art. 10. — Amputations of Convenience.
Anchylosis, complete or incomplete, deformities of different sorts, old and
incurable ulcers, or those the cure of which is never durable, affections which
hinder the use of some of the limbs, frequently induce patients to ask us to
relieve them at any sacrifice, although neither life nor health is compromised
by the existence of the malady. As a general rule, a prudent surgeon ought
always to resist the solicitations of those who consult him on this point. It has
been observed, in fact, that these operations which are called amputations of
complaisance, usually terminate unsuccessfully. In the year 1821, a robust
man in ^ood health and in the prime of life, came to the Hospital of St.
Louis with the fixed determination of having an operation performed at the
thigh for an anchylosis of the knee, which obliged him to use a crutch in
walking. After having remonstrated with him in every possible way, and
represented to him in the most forcible manner the dangers to which he
would expose himself, M. Richerand at last, although with great regret, ac-
ceded to his wishes. Amputation was practised in the most simple manner ;
no local accident occurred, but a low fever, which speedily developed itself,
brought on death on the fifth day after the operation. A similar fact is re-
corded by M. Pelletan. I also myself witnessed instances equally striking,
at the Hospital of Tours, in the years 1815 and 1820, and M. Gouraud, then
surgeon-in -chief to that establishment, came to a resolution to refuse in every
such instance. In 1825, a countryman, who had formerly been a soldier,
tired of carrying a dry ulcer behind the malleolus, presented himself in the
hall of the clinical department of the school of medicine, with the intention
of having the limb removed. M. Roux in vain endeavored to alarm him, by
representing the probable consequences of such an operation : the patient
was not to be shaken. Amputation was accordingly performed ; nothing parti-
cular occurred at the time of the operation, but in a few days, general symptoms
appeared, and the subject expired in about a week from the time of ampu-
tation. The worst of these cases is, that amputations the least important in
themselves, those of a finger or toe, for example, are often followed by
equally serious results. In 1829, a shoemaker who had had the left index
finger for a considerable time immovably fixed upon the palm of the hand,
came to me at the hospital St. Antoine. Prevailed upon by his solicitations, I
operated, and separated the finger from the corresponding metacarpal bone.
The amputation was not at first attended with any disagreeable consequences,
and the patient was eventually cured, but for fifteen days he was so seriously
affected, that on two different occasions I thought him beyond recovery.
Nothing is more frequent than cases of this description, and there is scarcely
a practitioner who has not observed a certain number of them. From these
circumstances has arisen the following surgical question among the moderns,
and which the ancients do not seem to have thought of: — ought the skillful
%.
OPFRATIVE SURGERY, 141
practitioneis to be influenced by the representations of the patients who may
apply to him ? ought he not rather flatly to refuse the performance of opera-
tions which are not indispensably necessary ? On the other hand, does hu-
manity permit us to condemn a patient always to bear an infirmity which
renders his life miserable, simply because, in relieving him from it, we should
expose liim te dangers more or less serious ? By this rule the surgeon ought
never to touch lupi, or tumors of any species which may develop themselves
upon different points of the body, for they are rarely dangerous in themselves,
and the operations which it is necessary to perform in order to remove them
are sometimes attended with the most serious results, and occasionally produce
the death of individuals the most robust, and apparently of the best consti-
tution. I am far from wishing to justify those who hastily practise amputation
of the members on occasions which do not absolutely demand it, for mere
inconveniences, or solely because it is desired by the patient 5 but I ask if it
is not conformable to the rules of sound surgery to have recourse to it for
deformities which cannot be otherwise removed, and which are of such a
nature as to destroy the natural use of an important part of the body, to
cause pain, and to be a source of constraint and continual suffering ; when
also the patient is in favor of the operation, after having fully reflected upon
the consequences which may result from his determination ?
^ Art. 2. — Gun-shot Wounds.
' f> —■
No wounds so frequently call for amputation as those which are inflicted
by fire-arms. Not that the projectiles impelled by gunpowder have in
themselves any venomous property, as has been believed by some surgeons
since the time of A. Ferri, and as is still imagined by the vulgar, but because
they break, tear, and bruise the tissues which they penetrate or strike.
A bullet, a grenade, or a portion of a bomb, which carries away a part of
the thickness of a limb comprising the vessels, demands amputation ; while
the same wound, produced by a cutting instrument, might perhaps be cured
without thus mutilating the patient.
If such an agent strike the body of the arm or thigh in such a manner as to
reduce the muscles to a jelly, but without affecting either the skin or the bones,
it is still necessary to amputate, excepting in cases where the attrition is very
limited, and the vascular and nervous trunks have escaped.
Wounds complicated with fracture also require this last resource. At the
articulations, if the injury is considerable, there is no room for hesitation.
There is no disagreement among practitioners upon this subject, excepting
when the articulation is not too extensively opened, and the osseous extremi-
ties have simply been pierced or cracked by a ball. Here the surgeon takes
account of circumstances. Is the patient in a situation to receive the neces-
sary attentions ? has the ball merely passed through the wrist, the elbow, the
instep, the shoulder, &c., shattering the articular extremities without lacera-
ting the tendons and other soft parts ? The preservation of the limb should be
attempted. But in the midst of camps and in crowded hospitals, when de-
structive epidemics are prevailing, and when the patient cannot obtain that
calm repose and those assiduous cares which are indispensable, and if the frac-
ture is accompanied by a splintering of the bone, if the ligaments, the synovial
membranes, or the tendons are bruised and torn, amputation will be found
more advantageous to the patient than delay. M. Labestide, it is true, de-
sirous of sustaining the principles of Bilguer, has brought together in his
thesis, a number of examples which prove that wounds of this kind, at the
1,4^ NEW ELEMENTS OF
wrist, the elbow, the foot, or the knee, have been cured without amputation.
Several observations of a similar description have also been collected and pub-
lished by M. Arnel from the practice of the hospital of St. Cloud, during
the days of July. Faure, Percy, and Lombard, had previously mentioned
similar facts. But how many cases of an opposite character may there not
be opposed to these instances of unhoped for success? The gardener of the
director of one of the theatres of the capital had a part of the metacarpus,
and some of the fingers of the ri^ht hand carried away by the bursting of a
gun 5 he was brought to the Hospital St. Antoine, where he earnestly entreated
me not to sacrifice the remaining tliumb and index finger. I gave way to his
entreaties. Serious symptoms shortly appeared, and amputation of the arm,
performed a fortnight after, failed to preserve his life. One of the individuals
wounded in Jul j, had the heel pierced by a ball and the tibio-tarsal articula-
tion opened behind and outwardly. The injury not being of any great extent,
M. Lisfranc and myself were desirous of preserving the member, but our
patient expired on the eighteenth day. Another person who had received an ex-
tensive wound, with fracture of the elbow and opening of the joint, underwent
no operation, and died, like the others, under the influence of the suppurative
fever Bud phlebitis. A young man in my service had the heads of the bones
and the articulation of the knee obliquely traversed by a ball, at the taking
of the Hotel de Ville. There was no splintering nor any laceration of the soft
parts : after a month's care it became necessary to amputate the thigh : this
was done, but did not prevent the death of the patient, which took place on
the thirteenth day after the operation. It is at least probable that amputation,
practised at firet, would have sftved the lives of some of these patients.
It is not only about the complex articulations that wounds from fire-arms,
with fracture or injury of the synovial cavities, are so dangerous; they are
scarcely less so at the middle part of the long bones, particularly of the in-
ferior members. Thus a simple ball, which shatters at the same time the tibia
and iihe fibula, almost always calls for amputation. For one person who re-
covers without submitting to the operation there are ten who die, however
trifling in extent may be the parts which have been injured or contused. At
the femur, amputation is still more formally indicated. Ravaton says, that if
amputation be neglected this fracture is almost always mortal. Schmucker
says that not more than one patient out of seven can be saved by any other
means. Lombard holds the same language. M. Ribes, who never saw a case
of this kind cured otherwise than by amputation, gives the history of ten
patients who died notwithstanding every care, and says that, at the Hospital
of Invalids, out of a total of four thousand individuals'he was not able to find
one who had been cured of this species of wounds. M. Yvan, in 1815, calls
the attention of M. Ribes to two cases of this description ; but the patients re-
tained fistulas, and eventually died in consequence of the fracture. I see
that M. Gaulthier, of Claubry, formerly surgeon of the Imperial Guard, is of
the same opinion as M. Ribes upon this subject; and says that those soldiers
of the Spanish army, whose thighs were fractured and upon whom amputation
■was not immediately performed, almost invariably died. Out of eight subjects
treated bv Mr. Samuel Cooper, after the battle of Ondenbosh, only one sur-
vived, and even he was not able afterwards to make much use of his limb.
Messrs. Percy, Tomson, Larrey, Guthrie, and J. Hcnnen, express themselves
nearly in the "same terms; and" the events of July, 1830, have induced almost
all the surgeons attached to the hospitals of Paris to adopt the same opinion.
One of the individuals, however, who was wounded on that occasion, re-
covered under the treatment of M. Lisfranc, at La Pitie. M. Dupuytren saved
m
OPERATIVE SURGERY. 143
a second, and M. Arnel mentioned three others. I was not so fortunate : only
one case of the kind called for my assistance ; the fracture appeared quite
simple, but nothing was able to prevent the death of the patient, which took
place on the thirty-eighth day. M. Somme cured two out of eight without
having recourse to amputaiion, during tl:3 events at Antwerp in Oct. 1830.
M. Lassis, and other practitioners of Paris and Belgium, have also published
several other successful cases 5 but it ought noL to be forgotten that with us,
as in Belgium, the wounded were treated with all that care which is usually
experienced by patients in civil practice ; whilst in the army and in military
hospitals, they are necessarily deprived of that tender treatment which in the
above-mentioned cities was so lavishly bestowed.
These successes besides were very few in number, and the member pre-
served generally continued in a deformed state, so that its loss could scarcely
have been more disagreeable to the patient. It is necessary here to remark,
that the fracture is so mucV the more dangerous as it approaches the middle
of the bone, whether on acceunt of the splinters which more frequently result
at that part, or from the number, disposition, and force of the muscles. On
the whole, amputation is the vnost frequently indicated in cases of commi-
nuted fracture of the inferior raembers. Except in extreme cases, however,
it may be frequently dispensed vith upon the upper extremity. To distin-
guish at first sight the circumstances which demand amputation and those
which enable the operator to dispense with it, is absolutely impossible. From
the earliest ages wounds extremely trifling in appearance have been seen to
become very serious, whilst on the other hand the most frightful injuries
have sometimes passed away without any particular ill consequence.
It is doubtless painful to be obliged to mutilate a patient who desires to
preserve his limb ; but is the argument drawn from certain unexpected cures
of subjects who have refused to submit to amputation, really entitled to the
value which has been so generally accorded to it ? Admitting that four out
of ten individuals thus treated are cured, is it too much to presume that if
they had all submitted to amputation, two-thirds of them would have re-
covered ? I leave conscientious men to decide whether the lives of two or
three men yet in the prime of their days, ought not to be preferred to the
preservation of a deformed member to four persons at the price of a thousand
dangers ?
Preliminary Attentions.
Art. 1. — Counter Indications
To justify an amputation, it is not sufficient that the disease which requires
it cannot be cured by any other means ; it is also necessary that the ope-
ration should promise entirely to remove it, and leave a reasonable chance of
preserving the life of the subject. When the operation is performed for a
cancerous affection, the operator should assure himself that no germ of the
disease exists in the viscera. If degenerated lymphatic ganglions are re-
marked at the root of the limbs ; if the color of the skin, the state of the re-
spiration, or of the digestion, or any, the least symptom, indicates that the
affection is not confined to the exterior, amputation will be useless, and will
only tend to hasten the development in more dangerous situations of diseases
analagous to those which it is intended to cure. The same remarks apply to
pulmonary phthisis ; to the necrosis and caries of the vertebral column; to ab-
scesses by congestion, the source of which cannot be stopped ; to any organic
144 NEW ELEMENTS Of
injury of the heart, of the liver, of the stomach, of the genito-urinary passage,
&c.; to extreme exhaustion ; to old and numerous ulcerations of the intestines,
combined or not with a colliquative diarrhoea ; in fact, to all those occasions
when, after the removal of the limb, a disorder is left in the organization suffi-
ciently serious to produce death. In rheumatic, scrofulous or syphilitic
affections, it is much to be feared that the malady would speedily reproduce
itself in other parts of the members, and would oblige the operator if he would
pursue it to practice successively several amputations. It is necessary there-
fore in these cases to have at least many chances of being able to limit the
progress of the general malady, even to cause it to retrograde, and at last to
eradicate it entirely. Prudence does not permit us, for example, to amputate
a member affected with caries or necrosis, scrofulous or syphilitic, if the articu-
lations of any of the other parts are the seat of swellings, pain, or any of the
first symptoms of a similar affection. In cases of scrofula, however, it has
been for a long time remarked that the removal of an important member is fre-
quently followed by an advantageous change in the constitution of the patient;
that weakness is sometimes succeeded by appearances of strength and the most
flourishing health. This effect is easily accounted for: an abundant suppu-
ration, continued pain, and a diseased articulation, form a cause of disease
which tends continually to deteriorate the functions, and cannot fail to keep
up such a state of the economy as will prevent the development of the natural
resources of the organization. By removing therefore this material cause of
suffering and danger, it is obvious thai the general health will be re-esta-
blished ; that ceasing to be obstructed or embarrassed in her efforts, nature
will soon cause the disappearance of the lesser evils, and triumph over a
malady the principal source of which has been destroyed. The first ques-
tion to be decided is, whether disease really exists in the interior, and what
is its nature ? because if it be incurable, amputation is not admissible. The
second relates to the source of the disease ; as if it be in the external affection,
amputation is formally indicated; if elsewhere, the reverse. Whenever the
local affection is the result of a general cause, it is absolutely requisite to
neutralize the first before proceeding to remove the second, sound practice
not permitting amputation until this has been done. A minute examination
of the patient is the more necessary before coming to a full decision, as the
greater part of the diseases which require amputation rarely fail to react
upon the splanchnic cavities, and to cause in the viscera either abscesses, or
tubercles, or ulcers, or indurations ; together with a thousand other morbid
foci, the appreciation or discovery of which is far from being always easy.
It is nevertheless well to remark, that the weakness with which some
patients are affected does not absolutely of itself forbid the operation. All
practitioners know that it is not always with the strongest patients, or those
who seem to have the best constitutions, that amputation most frequently suc-
ceeds. In fact, a certain degree of exhaustion, occasioned by long continued
pain ; even diarrhcea itself, when not kept up by any internal cause, are in
general rather favorable to the operation than otherwise. It seems in the first
case, that the organization enjoying perfect integrity revolts at the mutilation
which is practised upon it; whilst in the second, the affection against which
it has exhausted all its resources being removed, it has only to cause the dis-
appearance of the secondary disorders which it had not been able to prevent.
Art, % — Time for the Operation^
During the last century the question was much dgit^ted, whether, after se«-
OPERATIVE SURGERY. 145
rious wounds by fire-arms or otherwise, it were best to amputate immediately
or to wait for reaction. Faure, Boucher, Bilguer, Comte, and more par-
ticularly Schmucker, debated this point with great interest, on account of the
wars which were about to take place ; and although since that time it has
continually occupied the attention of the surgical body, the problem still
remains unsolved. The partisans of immediate amputation maintain that the
subject is in the most proper state for the operation, immediately after having
received the wound. There is then, say they, no fever, suppuration, or inflam-
mation ; the affection is wholly local, whilst at a later period, the swelling of
the member, frequently gangrene, an intense reaction, tetanus, and a thou-
sand other accidents, may bring on death before a proper moment can be found
for the operation. Even v/hen the violence of this reaction is calmed, say
they, the abundance of the suppuration, the separation of the muscles, the
fistulous passages which are formed, the induration and disorganization of
the tissues, render the operation very serious and difficult. The partisans of
consecutive amputation on the contrary, in order to justify their conduct,
maintain that immediately after a wound the organization is too much dis-
turbed, is under the influence of a too violent commotion, to permit the per-
formance of any operation with a probability of success, and above all, that
limbs are sometimes sacrificed which might otherwise have been preserved ;
whereas, after having combated the first symptoms, if amputation becomes
inevitable, the surgeon is at least saved from reproach. Taken according to
the letter, both these opinions appear equally contrary to sound practice.
When amputation becomes absolutely indispensable, when there is no uncer-
tainty upon this point, there can be no doubt that it is better to operate imme-
diately than to make any delay ; and Faure himself, who defended with so
much ardor the cause of consecutive amputation, is also of this opinion. When
on the contrary, there remains any possibility of preserving the limb, when
its loss is not irrevocably decreed, the operator ought to temporize, to combat
with energy the general symptoms, and also to decide upon amputation when
there remains no hope of obtaining a cure by other means.
Upon looking closely at this matter, it is easy to discover that Faure has
not placed it in its proper light. His ten wounded patients, it is true, had
all fractures ; the first, the ninth, and the tenth, at the leg ; the second, at the
femur; the third, at the knee ; the fourth and fifth, at the fore-arm ; the sixth,
at the humerus; the seventh, at the metacarpus; and the eighth, at the heel:
but none of these gun-shot wounds were so severe as to remove all hope of
saving the part. In these cases the question might have been whether the
operation was indispensable, but not whether it should have been performed
sooner or later. The result to which this surgeon has given so much import-
ance, does not in any way prove, that when the necessity of amputation has
become apparent it would be less dangerous to practice it after than before
the appearance of general symptoms. The very opposite conclusion might in
fact be drawn from it. What did M. Faure gain by temporizing ? Nine of
his patients were obliged to submit to amputation after having endured five or
six weeks of the most anxious uncertainty, and after having been in the great-
est danger of losing their lives. To say that these patients if operated upon
immediately ^vould not have recovered, is to make a supposition wholly gra-
tuitous. Reason tells us on the contrary, that these men who were able to resist
so many causes of death, would have experienced a more perfect cure, and
have been more fully restored to health, if, instead of being subjected to the
temporizing practice of Faure, they had undergone immediate amputation.
In admitting that secondary amputations succeed better than those which
19
146 NEW ELEMENTS OF
are practised immediately, the surgical academy is evidently wrong. To
tlie calculations of Faure, which go to prove that the successes are as three to
one, may be now opposed the experience of a host of respectable men who
have observed precisely the contrary. M. Dubor affirms that during the Ame-
rican war in 1780, the French surgeons lost almost all their patients by defer-
ring amputation, whilst the American practitioners, who performed the
operation immediately, were successful in every case that they undertook.
At the affair of Newburg, Percy was successful in eighty -six out of ninety-
two immediate amputations. Out of fourteen M. Larrey saved twelve. Of
sixty patients wounded in the naval engagement of 1st January, 1794, and
who underwent immediate amputation, only eight died. After the battle of
Aboukir, the eleven soldiers mentioned by M. Masclet, who were operated
upon during the first twenty-four hours, recovered, whilst three others upon
whom amputation was practised eight days later, died. The English surgeons
inform us, that after the battle of Toulouse, immediate amputation was attend-
ed with success in thirty-seven cases out of forty-eight, and that twenty-one
out of fifty-one died under a contrary practice. At the attack on New Orleans,
the proportion was still more favorable ; for out of forty-five immediate am-
putations only seven were unsuccessful, whilst by the other method only
two out of seven were saved. It appears also, that M. del Signore, surgeon
of the Egyptian army at the battle of Navarino, saved the whole of those
patients upon whom he practised immediate amputation, but lost twenty-five
out of thirty-eight of those upon whom the operation was delayed. Finally,
the events of 1831 have further proved the advantages of immediate ampu-
tation. About one hundred operations were practised (thirty at the Hotel Dieu,
fifteen at La Charite, twenty at the Gros-Caillou, thirteen at Beaujon, six or
seven at St. Louis, four or five at the Maison de Sante, three at Necker, one
at the School Hospital, one at St. Mery, and five at La Pitie), and in all these
cases, the superiority of immediate over consecutive amputation was fully
manifested.
The only question then is, whether amputation is or is not necessary ; and
the rules for deciding this point in each case, may be gathered from the
chapter on the diagnostic, or on indications.
Amputation ought to be practised immediately, that is to say within the
first twenty-four hours, before symptoms of reaction are developed ; in short,
as soon as possible, whenever there appears to be no chance of saving the
patient otherwise. The stupor and numbness with which some subjects are
aftected, is not a formal counter-indication. A Swiss, whose thigh had been
broken by a bullet, in July, and in whose case I had discountenanced ampu-
tation at UHopital de Perfectionnement, was operated upon by M. Guer-
sent, jun., and recovered. Only those cases should be abandoned which
appear to be beyond the reach of art. It is for the skillful practitioner to
distinguish the circumstances which render a temporizing practice necessary.
In doubtful cases he will wait, and combat or endeavor to prevent those
symptoms which may manifest themselves. If afterwards amputation be-
comes indispensable, it should be observed that it will rarely be successful if
practised during the acute stage of the symptoms, when the affection has not
yet become wholly local, and while there are evident signs of phlebitis or of
resorption. It is then that the viscera and their functions should be examined
with the minutest care, as the reaction, which may appear to have subsided,
frequently leaves purulent foci somewhere in the organization, which would
not fail to compromise the success of the operation. These remarks are not
confined to wounds inflicted by fire-arms, but are equally applicable to
OPERATIVE SURGERY. 147
injuries proceeding from other causes. Upon all points connected with this
subject, I recommend to practitioners a reference to the excellent work of
M. Gouraud (Principal Operator, Tours, 1815).
Art, 3. — Point of Amputation.
Amputations have been divided into two great classes: those which are
practised upon the body of the limbs, bear the name of amputations in conti-
nuity; the others, which are only disarticulations, are entitled amputations in
contiguity. Amputations are likewise practised at the point of election or at
the point o( necessity, according as the practitioner is at liberty, or is influ-
enced by the wound or disease, to act upon one part in preference to another.
Upon this subject it is scarcely possible to establish other than very vague
rules ; no rule, in fact, can be given which will not have numerous excep-
tions. Tlius it would not be always correct to say that the operation should
be performed as far as possible from the. trunk, or that the most slender part
of the member should be chosen.
The same remark applies to the rule which recommends that the amputa-
tion should always be practised above the injured tissues. The lardaceous
degeneration does not in any way demand the removal of the affected parts,
as It is sometimes advantageous to preserve them. It is commonly a symp-
tom of an alteration of the hard parts, and will speedily disappear, the same
as fistulous passages and the purulent sinus, when the cause which produced
them has been destroyed. It is sufficient in such cases to divide the bone
above its diseased parts, without being concerned at the state of the soft
parts.
Art, 4, — Preparatives.
1st. The attentions, both physical and moral, which ought to be bestowed
upon a patient; the preparations to which it is necessary to subject him
before an amputation, are the same as for all other grave operations ; the same
as in the operation for aneurism, for example, and vary according to an
infinity of circumstances. All times, all seasons, all hours of the day or night,
may he adopted for the practice of amputating, as well as for all urgent ope-
rations. The morning, however, is generally preferred when a choice of time
is given, as it is easier to watch the patient during the rest of the day, than
if the operation were performed at the setting in of the night.
2d, A method of amputating without pain, has long been thought a deside-
ratum. Theodore, and many others after him, have recommended to pass
under the nose a sponge steeped in opium, water of nightshade, henbane,
mandrake, lettuce, &c., previously prepared and dried in the sun, to throw
the patient into a profound sleep; afterwards waking him by using in the same
manner a sponge dipped in vinegar, or by putting the juice of fennel or rue
into the nostrils or ears. Others, from the time of Guy of Chauliac, con-
tented themselves, as has been subsequently practised, with administering
opium internally. For a long time a strap, drawn tightly round the limb
above the place where the flesh is divided, was believed to be the best means
of preventing pain. Very recently Mr. Hirckmann, of London, has returned
to the practice of the ancients; and maintains that it is possible to perform
the most serious operations without pain, if the patient is made to inspire, or
to take into his lungs in any way whatever a certain quantity of stupifying
gas. Magnetism has not been forgotten ; and all the journals of the day con-
tained an account of an amputation of the breast, which had been performed
148 NEW ELEMENTS OF
by M. J. Cloquet, without its being even perceived by the patient. Unfortu-
nately all these means are dangerous, if not inefficacious. It is only by his
address, his knowledge, and the skillful choice of instrunients, that the sur-
geon ought to pretend to diminish or shorten the pair of amputation. It is
much to be feared that the bistoury heated to the temperature of the body, as
recommended by M.Guyot, will prove equally unsatisfactory with the means
which have just been described.
S. Apparatus. — The instruments necessary for practising the most compli-
cated amputations, are a tourniquet, a garot, a cushion with a handle, or other
means of suspending for a time the circulation of the blood in the limb.
Knives of different lengths, a straight bistoury, a convex bistoury, a saw with
a change of blades, a dissecting forceps, scissors, curved or straight incisive
nippers, hooks, suture needles, and a tenaculum. For the dressing are re-
quired single, double, triple, and quadruple waxed threads, cut into ligatures
of different sizes and lengths; adhesive straps; lint raw, in balls and in
pledgets ; compresses, oblong, square, and of other shapes, together with band-
ages of linen and sometimes of woollen cloth. It is also necessary to have
at liand agaric, sponges, warm and cold water in different vessels, a little
wine, vinegar, and cologne water, a lighted candle, fire in a chafing dish, and
in case they should be necessary, some cauterizing irons.
Among these instruments there are some that demand all the attention of
the surgeon. The knives for example ought to be proportioned in length to
the size of the member about to be amputated. Wiseman recommended that
they should be made in the form of a sickle, in order to divide at once as
much of the soft parts as possible. This description of instrument was gene-
rally adopted for upwards of a century, but has been completely out of use
since the time of Louis, who proved its uselessness and its inconveniences.
Tiiey are now made completely straight, terminating in a broad and blunt
point. Others on the contrary are round at the extremity, wlnlst some are
narrow and very pointed. This latter sort is preferred by M. Lisfranc. The
best in my opinion, are those the edge of which is slightly convex, as recom-
mended by Lassus. With regard to its length, it is between the knives
adopted by the members or pupils of the old academy of surgery and those
of M. Lisfranc. Without being too sharp their point is yet not cut square,
and the heel is not required to form an angular projection in front of the handle.
The saw is an instrument which varies in shape still more than the knife.
It should be so heavy as to require only to be drawn across the bone in order
to its immediate action. Its blade should be properly set immediately before
the operation, so as to present a greater degree of thickness towards the
teeth, than towards the back ; a width of cut sufficient to enable the blade
freely, and easily to follow in the passage made by the teeth. This is effected
by the care of the workman, in turning the teeth alternately to the right and
to the left. Mr. Guthrie recommends that these teeth should be placed in two
parallel rows, the points of one row being turned backward and the other
forwards ; by which means says he, the teeth will penetrate equally well, going
and coming. This modification has not been adopted among us. It is neces-
sary always to have one or two spare blades. This is a principle which F. de
Hilden was induced to establish, in consequence of having been obliged upon
one occasion to leave an amputation unfinished until he had procured another
saw to replace one which had broken in his hand. The importance of this
precaution must be manifest to every one. I shall return to the other parts
of the apparatus, when speaking of their special application or of the particular
amputations.
OPERATIVE SURGERY. 149
4th. Position of the Patient. — In the hospitals the patient is usually placed
in the amphitheatre, or in a chamber particularly devoted to amputations. He
is there laid upon a table more or less elevated, and furnished with niatresses
and the necessary linen. In certain cases he is simph^ seated in a chair,
placed in a convenient position. Out of the public establishments a par-
ticular locality may be chosen, but in general the operation is performed upon
a bed or ciiair in the bed-chamber of the patient.
5th. A particular duty ought to be carefully assigned to each of the assist-
ants, before the operation. One of them is charged with the compression of
the artery. For this purpose the individual who possesses the greatest strengtii,
self-possession, and knowledge, is usually selected. A second embraces the
member towards its root, in order to draw up the flesh; a third sustains and
fixes the part which is to be removed ; and a fourth is charged \yith the duty
of presenting the instruments as they become necessary. Others are to hold
those parts of the body, the movements of which might be injurious during
the operation.
6th. To suspend the Circulation of the Blood. — Before carrying the knife
through the living tissues, it is necessary, to guard against hemorrhage, to
obstruct in some way the passage of the principal artery of the limb, until the
amputation will permit the final obliteration of the vessels. For this purpose
recourse was for a long time had to circular compression. This method was
adopted by Avicenna, by the Greeks, and even still later by Pare. Some of
the ancients, however, employed temporary hemostatic means, which were
more efficacious. It appears, in fact, from the very vague notions which we
possess respecting Archigenes, that that author even at that early period
made use of the ligature, which he applied immediately upon the artery after
liaving traversed the whole thickness of the part. By degrees the circular
ligature was improved in the hands of the French surgeons. They began by
removing it from the passage of the artery by means of a compress. In 1674,
Morel transformed it into a true garot by the aid of a small piece of wood,
v/hich augmented or diminished at will the compression of the vessel during
the operation. This garot, modified successively by Nuck, Verdue, and
Lavauguyon, is still used ; but to prevent the skin from being pinched, and
to hinder as much as possible the compression of those parts in the circum-
ference of the member which do not correspond to the artery, a compress
several times doubled, a rolled bandage, or any other solid lump or pad is
now previously placed over the vessel ; whilst a plate of horn, slightly concave,
•is applied to the opposite side of the member below the part of the cord which
is to be twisted. The tourniquet of J. L. Petit, invented towards the com-
mencement of the last century, and of which several modifications have been
proposed in England and Germany, has rendered the employment of the garot
of Morel much less frequent. The instrument of Petit, in fact, is so disposed,
that it acts w/ith a certain degree of force only upon the passage of the vessels
which are to be compressed, without hindermg the circulation in the colla-
teral branches. Besides, when once applied it may be left to itself, whilst the
garot requires to be incessantly watched until the close of the operation.
When the operator can only command a small number of assistants, or when
those assistants have not sufficient knowledge to entitle them to full confi-
dence, in the country, foi example, and sometimes in the army, wlien unfore-
seen circumstances render the amputation of a member necessary, the garot,
which can be fabricated immediately, forms an invaluable resource. The
tourniquet of Petit, if it could be procured would be better; but in all other
cases we should rely upon the hand of an assistant. When the artery is situ-
150 NEW ELEMENTS OF
ated in a deep hollow, it is well to use a sort of desk-seat furnished with a
cushion. In this manner the pain will be diminished, the retraction of the
muscles not in any way hindered, and the operator w'-ll act freely and be
able to approach the origin of the limb as nearly as the injury requires. In
some rare cases, however, the operator has recourse to a surer method. He
exposes the artery at a certain distance above the place where the amputation
is to be performed, and applies the ligature. But this forms a special indi-
cation, and will be considered in the sequel.
SECTION III.
METHODS OF OPERATION.
A. Amputations in Continuity.
These were almost the only amputations practised during a long series of
years, and are still more frequently practised tlian any others. They are per-
formed in three different ways, but principally by the circular and flap
methods.
Art, 1. — Circular Method.
In amputating by the circular method, the successive stages of the operation
are — the division of the skin, the division of the muscles, the division of the
bones, the prevention of hemorrhage, and the dressing of the wound.
§1. Manual.
1st. Division of the Skin. — Celsus, Archigenes, Gersdof, Theodoric, Wise-
man, &.C., in their day, as Louis, M. Dupuytren, and several others in ours,
divided the skin and the muscles at the same stroke. It appears on the con-
trary, that Maggi dissected the skin at first to such an extent, as to enable
him afterwards to cover the surface of the stump. But this method was
never followed by the ancients, and it is to J. L. Petit that we owe its general
introduction. That author, after having divided circularly the cutaneous
envelope of the limb, caused it to be drawn up by an assistant, or drew it up
himself to the extent of about two fingers' breadth. Cheselden pursued nearly
the same method and at the same time; but Alanson seems to have been the
first wlio recommended that the skin should be dissected and turned back so
as to form a sort of ruffle, a practice which was afterwards adopted by Lassus,
M.Richerand, and many other French surgeons. Messrs. Guthrie, Grjefe,
&c. think that the aponeurosis and some of the fleshy fibres might without in-
convenience be divided on the same stroke ; and that this would ensure the
complete division of the skin, and enable that membrane to be more easily
retracted. Hey and Langenbeck are of an opposite opinion. What advan-
tage, in fact, can result from this careful tracing of the periphery of the muscles
and the aponeurosis ? — whether the knife penetrate a little more or less deeply.
Provided the integuments are divided tnroughout their whole thickness, the
remainder of the operation will not be rendered more difiicult nor less so.
The surgeons who, like Hey and M. Brunninghausen, desire that tlie skin
should entirely cover the stump, have laid it down as a principle that the cir-
cumference ot the limb should first be measured, so as to preserve, for
example, two inches of the integuments for a v/ound which is to be four inches
OPERATIVE SURGERY. 151
broad. Lassus is said to have followed this direction with success. In my
opinion, these minute precautions are altogether useless. The best method,
when it is not intended to reach the bone at the first stroke, is to divide with
the knife the diiFerent cellular fibrous bands which connect the exterior en-
velope to the subjacent parts, Avhilst an assistant draws it back with more or
less force, as may be required. The pain is less, the skin preserves a greater
thickness, and nothing can be more easy than to raise it in this way to the
extent of two or three inches.
In order to make this division, the hand of the operator passes beneath the
parts describing a segment of a circle, and applies the knife upon the ante-
rior surface of the limb. It is useless here to follow the advice of Mynors,
to incline the edge upward so as to divide the integuments bevel-wise. The
incision should be made perpendicularly, the knife cutting from heel to
point, and circumscribing the member in as regular a manner as possible. ^
The hand is at first turned in pronation, and is gradually brought into supi-
nation as it passes first on the inside and afterwards beneath the member.
If the operator desires to make this incision at once, the hand turns gradually
upon the handle of the instrument in such a way as to be, at the end of the
stroke, in a forced state of pronation. By this method he will avoid that
disagreeable and fatiguing turn of the wrist which is experienced by the greater
part of those surgeons who do not perform the incision at two separate move-
ments. To a skillful practitioner it certainly would not be difficult to proceed
as I have directed; but I do not see what great inconvenience there can be,
after having divided the skin on the inside, on the outside, and beneath, in
withdrawing the knife as it is done by many surgeons, and with much ad-
dress by M. Blicke, of London, and carrying it above for the purpose of
uniting, by a second incision, the two extremities of the first. This, how-
ever, evidently is matter of choice, and not of necessity.
2d. Division of the Flesh. — The section of the muscles seems to have par-
ticularly fixed the attention of surgeons for about a century past. From the
time of Celsus the knife was carried a little above the dead parts, and the in-
teguments, together with the entire thickness of the flesh, were divided at the
first stroke. Celsus detached the deeper muscles and raised them in such a
way as to be able to saw the bone a little further up, and bring theiii down
again to cover the stump. This precept of Celsus has been long neglected,
and \Viseman, J. L. Petit, and Cheselden, in making the section of the soft
parts at two movements, seem also to have forgotten it. It was Louis who de-
monstrated that the conical figure of the stump, which was almost always left
by the ancient methods, was owing to the retraction of the muscles more than
to that of the skin, and consequently recommended that the muscular layers
should be divided at two movements. At the first stroke Louis divided the
integuments and the superficial muscles, which he caused to be drawn back
as strongly as possible, favoring their retraction by all the means in his power ;
the deeper strata were divided by a second stroke, after which he sawed the
bone in the ordinary manner. Le Dran says, " I cut at a single stroke the
integuments and half the thickness of the muscles; then I cause the skin and
flesh to be drawn back as much as possible, and then make a circular inci-
sion to the edge of the skin thus withdrawn ; by this second stroke I do not
cut the skin, but only the muscles down to the periosteum. This process is
very similar to that of Pigray or Celsus, and differs very little from that of
Louis. The latter author, however, deserves the credit of having improved
it, and caused its importance to be generally admitted. Valentine, in his
critical researches in surgery, imagined that it was necessary in dividing the
152 NEW ELEMENTS OF
muscles to place them successively in a state of extension at the moment of
incision; so that at the thigh, for example, the limb ought to be turned first
backwards, then outwards, then forwards, and finally inwards, while the ope-
rator made the circuit of the member with the instrument. This odd idea
never had, and never ought to have a partizan. Desault combined the
methods of Petit and Louis, that is to say, he recommends with the first of
these authors to divide and withdraw the skin in the first place; and with
the second, to divide afterwards the superficial muscular stratum as far up
as the skin was raised, and to commence the section of the muscles at the
place to which the first layer retracted.
Alanson published, in 1784, a new method of performing amputations. After
having dissected and turned back the skin, that surgeon divided all the
muscles at one stroke, taking care to direct obliquely upwards the edge of
his knife, and eventually to carry the point of his knife still more obliquely
completely round the bone ; his end being to obtain a hollow cone, the base
of which would be at the circumference of the wound. Langenbeck com-
bated tliis mode of practice, and Wardenburg attempts to prove that it is
impossible to have a conical wound by following to the letter the directions
of Alanson; ''inasmuch as the knife," says he, "held obliquely, must ne-
cessarily describe a spiral and not a circular line." Loefler and Loder, who
undertook the defence of Alanson a short time afterwards, endeavored to
prove, on the contrary, that it is not difficult to prevent this tendency to a
spiral course. It appears that upon this point Messrs. Langenbeck, Graefe,
&c., have misunderstood the process of the English surgeon. M.Dupuytren,
in fact, who has adopted it for a considerable time, and subjected it to some im-
portant modifications, uses it daily at the Hotel Dieu with the greatest success.
As the knife is penetrating, when it is directed obliquely it will be found suf-
ficient to hold its handle in a proper position, to prevent it from straying
from the circular direction. Alanson has also remarked that it is principally
with the point of the knife that the operator is enabled to cut out a cone from
the thickness of the muscles. In the process of M. Dupuytren, an assistant
forcibly retracts the soft parts, whilst the operator, holding the knife as directed
i)y Alanson, divides at a single stroke the skin and the entire thickness of
the flesh; he then carries tTie instrument without changing his hold about
the base of the fleshy cone, which rests upon the bone, in consequence of the
retraction of the superficial muscles ; this is done with extreme rapidity,
and there results from it the appearance of a hollow cone very favorable to
the reunion of the wound. Finally, Bell having divided the skin after the
manner of J. L. Petit, and the muscles by the method of Wiseman, carries
between them and the bone the amputating knife, in order to divide their
adhesions to the extent of about two inches, and raise them afterwards with
greater facility.
All the methods have undergone further modifications, which it is unne-
cessary here to mention. The brevity of the text of Celsus enables us to dis-
cover in that author the origin of the methods of Petit, Louis, Bell, and even
that of M. Dupuytren. If it is doubtful whether at that time any surgeon had
followed a method similar to those which are practised at the present day, it
is not so with the method thus described by Pigray. " After having retracted
the skin with both hands, the whole thickness of the flesh is to be divided
around the limb, above the disease : then, with a cleft-bandage, the divided
flesh is drawn back, in order to sav/ the bone as high up and as near to the
flesh as possible. The hemorrhage being arrested by caustics, astringents,
or a ligature, the skin is brought down and united in front of the wound, by
OPERATIVE SURGERY. 153
two stitches crossing each other. The most remarkable circumstance con-
nected with these apparently different processes is, that, when closely ex-
amined they are for the most part seen to lead to the same results. Whether
the operator incise at a first stroke the superficial muscles, and at a second
the deeper layer, after the manner of Louis ; whether he follow, on the con-
trary, the instructions of M. Dupuytren ; whether he divide the soft parts at
three strokes, as recommended by Desault, or whether he follow Alanson or
Bell ; if he but take the trouble to favor the retraction of the flesh, the bone
will be exposed at two, three, or four inches above the point where tiie incision
was commenced. In dividing the muscles therefore at the time of amputation,
it is much less important to conform to any particular rule than is generally
supposed. The method of Bell found, in 1829, a new defender in M. Hello,
a naval surgeon, who recommends that it should always be used in preference
to tlie formation of a hollow cone. From the trials that I have made of M.
Bell's method, it certainly does appear to me that the muscles thus detaciied
reapply themselves with greater facility, and are more easily put in contact,
and maintained face to face from the bottom towards the edges of the wound
than by any otiier method. It is only unfortunate that the operation is ren-
dered by it a little longer and more diflicult.
The most rational, sure, and generally applicable method is the following : —
The skin is divided at a single stroke, without a too rigorous regard to the
subjacent parts, and is drawn up by an assistant while the surgeon divides,
to the extent of two or three fingers' breadth, the filaments which attach it to
the aponeurosis or the muscles. Applied at the edge of the retracted skin,
the knife divides circularly all the muscles down to the bone, or at least near
enough to the bone to ensure the complete division of the superficial stratum.
The assistant then forcibly retracts the parts, and by a second stroke the ope-
rator incises all the fleshy fibres of the profound stratum at the place where it
begins to hide itself under the retracted extremities of the previously divided
muscles. Whether the knife is held obliquely or perpendicularly is of no
consequence to the definitive result; and whether the operator penetrates at
first to the bone, or simply to the deep seated muscular stratum, is also almost
the same. In both cases it is equally necessary to carry a second incision
two or three inches above the first, through the most adherent muscular fibres.
3d. Section of the Bones. — The muscles having been divided, are drawn
up by the aid of a retractor. For this purpose, woollen or linen bags, or
plates of leather and even of metal were formerly used. F. de Hilden, Gooch,
Bell, and Percy, praised these instruments ; but surgeons of the present day
are content with a simple cleft compress, the undivided part of which is laid
upon the posterior part of the flesh rather than upon the anterior, as recom-
mended by M. Graefe ; its two free extremities are crossed and turned in
front ; and the assistant, who embraces the whole with his hands, thus draws
back the soft parts in order to protect them from the action of the saw. Be-
fore proceeding farther, most surgeons recommend that t\\^ periosteum should
be carefully divided and scraped away. Wiseman performed this denuda-
tion with the back of his amputating knife. Since his time, however, the
bistoury or the edge of the ordinary knife has been preferred. Some practi-
tioners, with M. Gr£Efe, scrape downwards ; others, with M. Brunninghausen,
push the membrane upwards, in order afterwards to bring it down upon the
track of the saw. These are all useless precautions, as has been proved by
Messrs. Alanson, Guthrie, and Cooper, and before them, by J. L. Petit and
Le Dran. They are recommended for the purpose of lessening pain, and pre-
venting tetanus and the exfoliation and inflammation of the bone, together
20
154 NEW ELEMENTS OF
with the suppuration of the surrounding parts ; as if the periosteum could exert
the slightest influence upon the production of such phenomena! When it has
been carefully divided, one of two things must happen : 1st. The saw is car-
ried a little higher than the denuded part without its being perceived by the
operator, and then the scraping is of no eft'ect. 2d. The saw is indeed applied
upon the intended place, and in that case it is difficult to avoid leaving a
small part deprived of its envelope, which circumstance will almost necessa-
rily produce necrosis. On the whole, then, if the surgeon attains the proposed
end the precaution is hurtful, and if he fails it is at best useless. We should
then confine ourselves to detaching the fleshy fibres exactly, with the knife
or bistoury. That done, the operator embraces the member with the left hand,
placing the thumb immediately above or below the point which is to sustain
the action of the instrument. The saw, held in the right hand, is applied per-
pendicularly and moved rapidly to and fro with short strokes until a way is
made ; afterwards it is drawn from heel to point, and pressed very lightly.
Wliilst there is yet considerable portion of bone to be traversed by the saw
the operator may proceed quickly, but when he approaches the end of the
division he must observe the greatest caution. At this period the assistants
also should redouble their care to maintain the opposite parts of the member
in their natural direction. If the assistant who holds the diseased part lower
it, the bone will inevitably break before it has been entirely divided ; if he
raise it, on the contrary, the action of the saw will be impeded and the ope-
ration thus rendered more difficult. It is necessary also, that the operator
should be habituated to the use of the instrument, and that in sawing he should
be careful not to incline it either to one side or the other. With attention to
these instructions the bone will generally be cleanly divided. But if any
points or asperities remain at its extremity, they should be immediately re-
moved either with incisive pincers, which are generally used, with a small
saw, which appears to me to be the best instrument or, when they are suffi-
ciently long, with the same saw which has been used for the amputation. The
edges of the section are usually so sharp that some surgeons, such as Messrs.
Graafe and Hutchinson, have recommended that they should be rounded with
a tile or with the edge of a short and firm scalpel. This practice, however,
is not imitated by other surgeons ; both theory and observation unite in demon-
strating its inutility.
4. Ilamostasis. — Immediately after the section of the bone, the operator
removes the cleft compress and proceeds to close the vessels.
A. Topicals. — We do not now, as in the time of Paul of Egina, cauterize
the wound with a hot iron, boiling oil, or melted lead; nor stufl' it with
oakum or plasters smeared or saturated with the white of eggs, bole arme-
nic, or oilier astringents, used by Guy of Chauliac, and almost all the surgeons
of the middle ages ; nor have we recourse to arsenic, vitriol, or alum, still
more lately recommended by Lavauguyon and Le Dran ; nor, finally, employ
the sponge, or agaric of the oak, as was proposed by Brossard and Morand
towards the middle of the last century. M.Binelli, however, says, that with
a water of Ins invention it is easy to arrest every kind of hemorrhage; and
several experiments seem, in fact, to support liis assertion. M. Bonafoux
composes with charcoal, gum, and colophony, a powder which he recommends
as possessing the same properties. Finally, Messrs. Talricli and Grand have
discovered a liquid, the efficacy of which has been put out of doubt by nume-
rous experiments upon dogs, sheep, horses, &c. ; but application of these
novel means having never yet been made upon the human subject, I abstain
from any further discussion of them.
OPEBATIVE SURGERY. 155
B. The ligature is justly preferred. Pare is the author of this important
modification. If Galen, Avicenna, Tagault, and some others, had already
mentioned it, it must be confessed that it was without advantage to the prac-
tice of surgery. F. de Hilden, Wiseman, Dionis, and De la Motte, who
speedily adopted it, were not long in causing its general dissemination, and
now for a long time it is only by way of exception that it is ever neglected,
or that other means are substituted in its place. The operator commences
with the principal artery, inasmuch as it is more easily found than any other,
is more necessary to be obliterated, and because the other arteries will also
afterwards be discovered with less difficulty on account of the greater quan-
tity of blood which will be conveyed to them. The principal artery then is
talcen up with pincers, embracing its whole thickness, but carefully avoiding
the nerve and vein. Some practitioners, Desault, Hey, &:c., have however
recommended, at least for the great trunks, that the operator should reach
and tie at the same time the deep artery and vein, by directing one of the
branches of the pincers into the mouth of each. They intended by this means
to guard against hemorrhages which miglit arise from the great veins. The
moderns reject this practice ; first, as useless, and afterwards as dangerous ;
useless, because the concentric circulation of the veins does not permit the
blood to escape by their mouths into the body of the stump, and because even
if that accident happen it is not necessary to have recourse to the ligature;
dangerous, because, say they, in strangling a great vein the operator runs the
risk of producing inflammation in its coats. As to the ligature of the nervous
cords, that is a practice which all agree in discountenancing. Instead of pin-
cers, Bromfield, and the greater part of English surgeons make use of the tena-
culum; but this instrument, although it renders the application of the thread
more sure and easy, is not so convenient as the pincers for seizing the vein
and drawing it out without laceration ; this is no doubt the reason why the
tenaculum is rarely used in France. But whichever may be used, when once
the artery has been seized the operator endeavors to bring it out from the
surface of the wound; an assistant then passes a thread beneath it, bringing
the ends together above so as to form a loop, which he passes beyond the'
end of the pincers : these are then turned horizontally. It is tightened by
seizing its extremities with the last fingers of both hands, and drawing them
upwards, while with the fore-fingers and thumbs the knot is pressed as deeply
as possible into the w^ound. Some persons, according to the advice oF
M. Richerand, prefer pulling upon the thread in such a way as to draw the
extremities backwards, beyond the place where the artery is found. If the
vessel is found at the bottom of an excavation, the same end will be attained
by holding the ligature away from the knot on each side with the fore-fingers,
which there represent a sort of pulley. All these rules, however, are unne-
cessary to a surgeon of any intelligence ; every such practitioner will adopt
tliat method which appears to him the- most convenient and the most safe.
The principal artery being closed, the others are carefully sought for and
successively obliterated in the same manner, except that it is unnecessary to
isolate them so exactly from the small veins and other tissues which surround
them.
Single threads are employed for vessels of the second or third order, and
double or triple ones for the great trunks. In England, where fine ligatures
have been generally adopted in the treatment of aneurisms, double and triple
threads are no longer used after amputations. The principal artery is some-
times so hard, and encrusted with phosphate of lime, as to crack like glass
under the application of the ligature ; in these cases a small cone of linen.
156 . NEW ELEMENTS OF
cork, elastic gum, or any other similar substance, should be introduced within
it; or a small cylinder, like to that which is called Scarpa's roll, should be
placed between the artery and the ligature, which ought to be larger than
those used for healthy trunks. Finally, it has been thought by some that
simply flattening the vessel would be a sufficient precaution against hemor-
rhage.
Sometimes the blood escapes from the interior of the bone, either by transu-
dation or from the trunk of its proper artery. A small graduated compress
applied upon the place from which the blood issues, whilst the operator seeks
the other vessels, will usually, says Mr. Ramsden, be found sufficient to
arrest this hemorrhage ; otherwise it would be necessary to have recourse to
cauterization, or to place a morsel of wax, or plugs of lint or agaric in the
medullary canal. A great number of arterial branches may be seen during this
operation which cannot be found immediately afterwards, and which sometimes
a little later cause a very abundant flow of blood. This phenomenon is ex-
plained in a way which appears to me any thing but satisfjictory. I do not
see why the momentary absence of hemorrhage should be attributed to spasm
of the divided arteries, to their retraction, or to the instantaneous action which
the air exercises upon them. If they seem to reopen at the expiration of a
few hours, that circumstance is evidently produced by the concentric deter-
mination of the organic actions consequent upon the operation, which after-
wards gives place to an eccentric movement — a reaction more or less lively,
whicii carries the fluids back from the interior towards the exterior. The
practice followed, first by Parrish, in America, by Klein, in Germany, by
several surgeons in England, and even by Messrs. Dupuytren and Lisfranc,
in France, of leaving the wound open for several hours in order to give time to
the lesser arterial branches to return to their natural state, does not appear to
be in accordance with reason, and I believe I may permit myself to condemn
it as a general method.
Since immediate reunion after amputation has been proposed and followed
by a great number of practitioners, there has been an endeavor to leave as few
foreign bodies in the wound as possible. They begin by cutting one of the
ends of each ligature very near to the artery. M. Weitch, who believed him-
self the inventor of this modification, insisted strongly, in 1806, upon the
advantages which resulted from it. He employed then, as has since been
recommended, very fine silk threads, in order to be able to cut both ex-
tremities and leave the knot about the artery. Drs. Haire, Wilson, Belcombe,
Maxwell, Hennen, &c. had followed this practice long before it was men-
tioned by Mr. Lawrence. Messrs. Collier, S. Cooper, and Delpech, have also
tried it with success ; nevertheless, Messrs. Cross, Dauning, Guthrie, &c.
have remarked that these ligatures frequently produced secondary abscesses.
It appears, moreover, from the researches of Messrs. Hennen and Carwar-
dine, that this practice of cutting the ends of the ligature very close to the
knot, was followed in diSerent countries of Europe from the year 1780. As
it appeared that thread or silk could not be absorbed, but acted always
as foreign bodies, ligatures formed of other substances were introduced.
Ruysch had already proposed broad strips of leather, the use of which Beclard
has revived in France. In America, Dr. Physick tried ligatures of deer-skin.
These latter are much praised by Dr. Jameson, who has long employed them.
Others have had recourse to catgut, &c., and to the intestines of silk worms;
but experience has not yet pronounced upon the real and definitive merit of
these diiferent substances. Ligatures of thread, single or double, according
to the volume of the artery, are generally used in Paris. When they have
OPERATIVE SURGERY. \57
been applied, and before proceeding to the dressing, one of the ends is cut
very near to the vessel, in order to diminish tlie mass which they form in the
midst of the tissues ; the other extremity remains on the outside of the wound,
and serves to withdraw the knot when it has become detached from the artery.
C. Compression. — M. Koch, surgeon of the hospital of Munich, affirms that
for more than twenty years he has not in any case had recourse to the liga-
ture after amputation. He confines himself to compressing the principal
artery of the member by means of graduated compresses, and a rolled band-
age extending from the trunk almost to the wound, which he unites imme-
diately. Numerous facts, he says, support this practice, and prove that it is
not necessary to tie the arteries in order to prevent the passage of the blood
to the surface of the stump. A question of a serious nature seems to me to be
at the bottom of these assertions. The annals of science contain facts with-
out number, which prove that the most voluminous arteries may be divided
without giving rise to any effusion of blood. Every one knows that lacerated
wounds, amputations after gangrene, and wounds by lire-arms, have often
astonished practitioners in this particular. S.Wood had the shoulder torn
off by the wheel of a mill, and was cured without an artery being tied.
l)e la Motte, Carmichael, Dorsey, and Mussey, each report a similar case.
A child nine years of age, mentioned by Benomont, had its leg torn off, and
was cured in the same manner. In another case, the thigh, violently sepa-
rated from the haunch, was unattended by any flow of blood. The ampu-
tation of the thigh related by Tcheps, Scharschmidt, Theden, Thomson,
Messrs. Taxil, S. Cooper, Beauchene, Segond, Labesse, presented the same
phenomenon. Messrs, Arbe, Lizars, Mudie, Smith, and Flandin, mention
several amputations of the leg, arm, fore-arm, &:c., which were attended with
similar results ; and I have myself witnessed several cases of the same
description.*
The researches which I have made upon this point of practice, have led me
into several experiments the principal results of which are here detailed : —
D. 5rjiisi7io-.-^Bruising is rarely sufficient, except for small arteries ; if those
who practise it after having cut or torn the cord of newly-born infants ; if the
animals who effect it by chewing the umbilical cord of their young, succeed
thus in preventing hemorrhage, it is because the circulation generally ceases
of itself in the umbilical vessels after birth. Nevertheless, after havino- em-
ployed it successfully upon the epigastric artery and those of the leg and
fore-arm, I can conceive that Le Dran may have contented himself with this
practice after dividing the seminal cord of man.
E. Plugging. — A cone of alum or sulphate of iron, about three times in
length, placed in the crural artery and even in the carotid of a cat or doo-,
fixes itself promptly, and is generally sufficient to arrest the effusion of bloocf ;
but the species of eschar which results from it preventing immediate reunion,
it is possible that the blood may re-appear at the coming away of this foreign
body ; it should be added too, that its introduction is not always easy except
in the great arteries. Wax produces the same effects, but being more slip-
pery and exerting no chemical action upon the vessel, it requires to be thrust
m more deeply : nevertheless, if when it is introduced the operator pushes
it downwards with pincers or with the fingers through the walls of the vascu-
lar tube, the extremity of which he at tlie same time holds firmly closed,
there will be formed a sort of knot, which the blood will have some difficulty
in removing. The stylet which Chastanet seems to have used long since for
♦Journal Hebdomadaire, 1S30-1831.
158 NEW ELEMENTS OF
the same purpose, though less sure, yet quite frequently effects the obliteration
of the artery. The point of a bougie is far better, at least whenever it is made
to penetrate not less than an inch. Catgut, deer skin, or chamois leather,
being scarcely foreign bodies, offer still greater advantages, in consequence of
their presenting no obstruction to the immediate closure of the wound. These
different substances form a species of cork, the manner of using which is too
simple to require a particular explanation. M. Miquel, of Amboise, made
simdar observations at the close of the year 1828. I have incontestably
proved, says he, by thirteen experiments, that by introducing into the arteries
of a dog a foreign" body, particularly an instrumental cord, a morbid state is
speedily and invariablj" produced, which renders them incapable of receiving
the blood, although they may not be mechanically obliterated.
F. Folding back. — AVhen it is not too difficult to isolate the artery in order
to fold it upon itself, as was practised by Theden upon the intercostal, and
by Le Dran upon the whole of the cord, after castration, this method will
almost invariably stop the flow of blood. To do this it is sufficient to bend
back the extremity of the vessel, to double it, and to push it a little way into
the flesh, or to close the wound immediately over it, in order to maintain the
artery in the position that has been given to it. A branch of the external
mammary and two branches of the subscapulars, thus treated in the month
of August, 1828, at the hospital of the school of medicine, in the case of a fe-
male upon whom I had operated for an enormous tumor at the left arm-pit, were
unattended with the slighest flow of blood. The same is true of an a^ed
woman whom I relieved from a cancer in the breast, towards the termination
of the year 1829, at the Hospital St. Antoine ; and of a third patient in the
month of January, 1830, in whose case I was obliged to remove the first meta-
carpal bone. As it is possible, however, that without this doubling tlie flow
of blood might have ceased, prudence recommends delay in coming to a
conclusion, notwithstanding the authority of Mr. Guthrie, who, after having
said that the slightest pressure exercised with the extremity of the fore-finger
suflices to arrest hemorrhage, adds : *' If the orifice of the artery, whether by
the effect of a natural curvature of the vessel or by accident, retracts or
turns to one side in such a way as to put itself in contact with a somewhat
solid muscular surface, that simple contact will prevent any escape of blood.
G. The perpendicular compression, which J. L. Petit endeavored to intro-
duce during the last century, has not been adopted. By directing plugs of
linen, agaric, sponge, or lint, upon the arteries at the bottom of the wound,
with the assistance of a machine, we should but aggravate the usual results
of the operation, without being sure of preventing hemorrhage. Even in his
famous case of the Marquis of Roquelin, Petit would have done better in
exposing the principal arterial trunk of the limb above the solution of conti-
nuity, than in proceeding as he did upon that occasion.
Sometimes tne arteries are so deeply hidden in the flesh after amputation,
that it is impossible to seize or take them up with either tenaculum or pincers.
On these occasions, if they are at all events to be tied, a thread must be passed
round them by means of a suture needle, at the risk of embracing more or
less of the circumjacent tissues.
7. Torsion. — A question completely novel, as it springs from the experi-
ments before referred to, is that of torsion, as a substitute for ligature after
amputation. I was conducted to this discovery, in 1826, while putting to the
proof upon dogs the various known means of preventing hemorrhage. I had
never tried it upon man, and had not sufficiently varied my experiments upon
animals to permit myself to speak upon the subject, except to the students
OPERATIVE SURGERY. 159
who attended mj lectures upon surgery, at the close of the year 182r. But
on the 13th November, 1828, after having amputated the arm of the girl Rohan,
in the presence of Messrs. Al. Dubois and Mai teste, I twisted the radial and
ulnar arteries, doubled back the anterior interosseal, and immediately closed
the wound. No hemorrhage resulted, and a cure was effected in twenty-
tiiree days. On the 4th December following, I followed the same mode of
procedure and with similar success, after the amputation of the first meta-
tarsal bone. The patient was a strong and vio;orous male adult. It was not
however until the 21st September, 1829, that I practised amputation of the
thigh without ligatures. I had to twist only the crural artery, and two small
muscular branches. No hemorrhage, followed. The youn^ girl, nineteen years
of age, who did well until the fourth day, died on the twelfth. An examination
of the body discovered several purulent and tuberculous collections in the
lungs. The articulation of the hip was in the height of suppuration. Some
days later, the 26th of the same month, I did nearly the same, after ampu-
tating the arm of a young man twenty-three years of age. The humeral artery,
the great anastomotic, and two branches of the external collateral, were twisted
without difficulty, but several other branches offered greater resistance.
Seeing, at the expiration of a quarter of an hour, that in spite of the tourniquet
the blood continued to flow', I removed the dressings. Nothing flowed from
the twisted arteries. The hemorrhage proceeded from those which had been
bruised, and from three others which I had not at first perceived. I tied them
all, and the blood did not re-appear. The patient died on the sixth day, and
the examination of the corpse discovered no other lesion than a deep disease
of the scapulo-humeral articulation. The vessels both arterial and venous,
presented no trace of inflammation, and the arterial extremities, firmly closed,
were in both these cases lost, as it were, in the midst of the other tissues.
I became from this time convinced that torsion would succeed as well upon
the arteries of man as upon those of dogs, and that in cases of necessity it
would be possible to use it instead of the ligature. It remains to be seen
whether it is better and ought to be preferred to the latter. The experiments of
M.Thierry, who was unacquainted with mine first made upon horses, and com-
mencing at the beginning of July, 1829 ; those that M. Amussat made known
to the academy on the 15th of the same month, three years after my first attempts,
and which he has so frequently repeated since ; those of Messrs. Lieber,
Klu^e,Schrader, Tyro, Reigner, and Dard,upon animals; of Blandin, Iloux,
Ansiaux, Fricke, Dieft'enbach, Rust, Fourcade and Bedor, Lallemand and Del-
pech, Guerin^Jobert, and Key, upon 'the human subject, without definitively
decidingthis question, are sufficiently numerous to render its solution probable.
Modes of Operation. — Like every thing else which depends \ipon the hands
of men, the manner of twisting the arteries will vary according to the ideas or
caprices of each practitioner.
1. M. Thierry, who recommends that it should be done parallel with the
axis of the vessel, contents himself with seizing the divided tube by its ex-
tremity with Percy's pincers, or rather with pincers the chaps of which should
be larger or smaller according to the calibre of the artery, and turns it upon
itself from four to eight or ten times, without fixing the base.
2. In Germany several other modifications have been already proposed.
M. Kluge, for example, boasts much of an instrument of his invention, which
by unloosing a spring, causes the pincers to turn upon themselves.
3. For my own part I use any kind of grooved pincers, or even the ordi-
nary ligature pincers. After having seized with this instrument the vessel at
its extremity, I isolate it from the surrounding tissues, and then seize it towards
iF »'
160
NEW ELEMENTS OF
its. root at the bottom of the wound with another pair of pincers, so as to fix
it, or perhaps with the thumb and fore-finger, whilst with the lirst pincers I
turn it upon its axis from three to eight times, and not three times onlj for
the great arteries, as I have been erroneously made to say.
4. M. Amussat recommends that the artery should be seized with pincers
having round branches, and drawn out some lines from the bleeding surface ;
that after itibas-been carefully isolated from the veins, the nervous filaments,
and all the tissues which surround it, the blood which it contains should be
crowded back, and that it should be fixed towards its root with a second pair
of pincers, whilst th.e first pair break by gentle movements the internal and
middle tunics ; that the extremity of the artery should then be twisted
somewhat rapidly from six to ten times at the same time that the stationary
pincers fix it, without pressing it too much towards the flesh, and that as soon
as the rupture of the inner membranes has been accomplished, they should be
crowded back in the direction of the heart, by acting through the cellular
tunic as I have described under the article aneurism. Instead of pusliing
back and leaving the isolated part of the artery at the bottom of the wound,
the operator may continue to twist it until he detaches it completely, and leave
only a sort of gimlet point in the middle of the wound. "Nevertheless, it
must be acknowledged," says M. Vilardebo, from whom I borrow these details,
"that these manoeuvres are more easily executed when tlie torsion is limited
by the fingers than when the operator makes use of two instruments. The
second pincers are only useful in fraying the artery and crowding back the
broken coats. After, this, the thumb and the index finder of the left hand
seize the extremity of the vessel at the point beyond which the inner coats
have been pushed, and makes first several turns with the pincers, to which
the operator afterwards approaches the fingers and continues the twisting a
moment longer ; he seizes the artery still nearer and nearer to the instrument,
always continuing the torsion, and so on till the fingers meet the instrument.
The operation is terminated by rolling the spiral thus formed into the shape
of a cork-screw, and by pushing it into the depth of the parts."
Remarks. — Two things require to be separately considered in this process,
1st, the isolation, and 2dly, the torsion of the vessel. The first, which applies
equally to the ligature and to torsion, is incomparably the most difficult and the
most complicated. Although the great arteries, surrounded by healthy tissues,
flexible and elastic themselves and free from disease — all those which are
seated in the muscular or cellular interstices, may be easily enough taken up,
divested of the surrounding lamellae, lengthened and drawn oiit several lines —
it is far from being so with those which creep along in the thickness of some
of the tendons or of voluminous nerves, and which adhere by their circumfe-
rence or their external surface to the fatty strata that envelope them ; which
are fragile, scarcely perceptible, crushed by the least pressure, and which one
is afraid to let go when they have once been seized. If it were absolutely
necessary, the operator might doubtless reach them in the majority of cases
with time, address, and precaution. But what benefit would result from this?
It is an error which has been a hundred times demonstrated, to believe that
it is dangerous to comprise a few lamella of the cellular tissue, or fleshy fibres
in the ligature at the same time with the artery. Nervous filaments, and even
small veins intercepted in this manner, do not in reality give rise to any other
inconvenience than that of causing for the time a slight increase of pain. One
must be a stranger to the habitual practice of the great hospitals, to charge to
imperfect isolation of the arteries the accidents which so frequently follow
amputation. So that it is only in applying torsion, that these preliminaries are
^
OPERATIVE SURGERY. 161
indispensable; from which it follows, let us say at once, that as regards
execution the ligature will always hare the advantage. Happily, we may
safely neglect a part of the instructions, given by M. Amussat. In following
them to the letter, M. Jobert saw the hemorrhage reappear by the twisted
arteries. Mr. Fricke, who follows almost the same method as myself,:
Messrs. DieiFenbach, Rust, &c., who have only partially adopted these
instructions, have rarely observed the same inconvenience. It is not
because I have continued to employ my own mode of procedure that the
torsion has sometimes miscarried in my hands. Wherever the vessel
was easily taken up, caused to project, fixed behind with other pincers or
with the pulp of the two fingers, the obliteration was perfect, although I
might not have thought it necessary to isolate it farther. For the rest, this
difficulty is the only one, so far that I know to be connected with torsion.
When the favorable conditions which I have mentioned above manifest
themselves, and the practitioner gives the necessary attention to the operation^
the arteries will be as firmly closed as if they had been tied. The inflam-
mation and suppuration, whether external or internal, €«f the vascular and
nervous fasciculus, do not appear to be more likely to occur after torsion than
under the influence of the ligature, except perhaps when the torsion is prac-
tised with a simple pair of pincers, and without taking the precaution to limit its
extent towards the heart, as in the process of M. Thierry, for example. At
least there is nothing in the facts publishetl at Berlin, at Hamburgh, and at
Paris, together with those which have come under my own observation, to show
that the fears of the professor of MontpeUier have any foundation. The re-
proach which has been thrown upon torsion of leaving a piece of the artery
to act as a foreign body in the wound, appears to me without foundation. Id
the two subjects operated upon by me at the Hospital St. Antoine, this vascu-
lar stump, still distinguishable, was firmly united with the surrounding tissues
so as to give no further trouble, and I have never heard that other prac-
titioners nave shown this circumstance to have an injurious tendency. Thus,
the only undeniable defedts of torsion are that it does not always offer so
much securit^p^ as the ligature ; that it is not applicable in all cases ; that it
requires considerable skill and practice to execute it properly ; and that it
renders the operation longer and more fatiguing. On the hand, by leaving no
foreign body in the wound, it offers the great advantage of favoring imme-
diate union, of off*ering no irritation to the bleeding surface, and of helping
us to bring about a cure without suppuration. In this respect, however, the
attempt of the operator will scarcely be satisfactory. The patients of M.
Amussat, with the exception of a child who recovered at the end of twelve
or fifteen days, were not cured sooner than they would have been by the
use of the ligature. Union strictly by the first intention has not been ob-
tained by Messrs. Fricke, at the Hamburgh Hospital ; Ansiaux, at the Liege
Hospital ; Dieftenbach and Rust, at the Berlin Hospital ; Guerrin, at Paris;
Bedor and Fourcade, at the Troyes Hospital ; Lallemand and Delpech, at the
Montpellier Clinique, nor by Key, at Guy's Hospital, in any cases of ampu-
tation whatever. This being the case, torsion has no real claim to preference
except in some operations which are practised upon the soft parts alone. In
fact, ligatures well applied, can always be removed at the sixth or twelfth
day : and a host of facts prove, that after their removal, eight or fifteen day8>
and sometimes less, suflBce to complete the cure. And we cannot see how an
extensive wound, comprising bone, muscle, aponeurosis, so many different
tissues through the whole thickness of a limb, can be fully cicatrized, firmly-
united in less than twelve or twenty days. On the whole, I believe that after
21
162 NEW ELEMENTS OF
amputations it is useless to be at much pains in twisting those arteries which
present any difficulties in the way of torsion ; but that it would be better to
tie them at once, leaving to torsion in such cases the rank of an exceptionary
method.*
§ 2. Dressing.
There are two general methods of treating the wound resulting from ampu-
tation ; sometimes the lips are united as exactly as possible, and the most
perfect contact is aimed at. Sometimes, on the contrary, they are kept apart
by placing between them foreign bodies and several pieces of dressing. In
the first case the operator seeks to obtain what is called immediate union, or
hy first intention; in the second, suppuration is favored, and the cure or cica-
trization is only ohta.me6. mediately or by second intention.
A. Mediate Reunion. — Until the end of the last century surgical writers
speaT: only of mediate reunion after circular amputation, but the operation was
far from being always performed upon these principles.
The ancients were m the habit of filling the wound witli compresses or
sponj^es dipped in vinegar; treating it in all respects like all other solutions
of continuity in which they wished to bring about suppuration. Those who,
like Archigenes, Heliodorus, Paul of Egina, &c., had recourse to cautery to
suspend the hemorrhage, made use at first of garlic and, salt to cause the
separation of the eschar, and afterwards of cataplasms of honey, meal, eggs
or simply of emollient substances. The Arabs have particularly vaunted the
use of astringents, styptics, and bole armenic; they also frequently employed
the balm of sulphur. F.de Hilden thought to simplify the dressing by .en-
veloping the stump in a woollen bag stuffed with different substances. Wise-
man preferred Fabricius' bag — the bladder of an ox. He employed also the
dry suture to bring the lips of the wound a little nearer together. Sharp
wished to discard the hot iron ; but in order to hinder the soft parts from
retracting, he had recourse, like Pigray, to two ligatures crossing each
other in (ront of the stump. This was the progress to the mode which was
generally followed towards the close of the last century. At the present day
it is -practised in the following manner :-^Some practitioners bring together
the ligatures into a cord at the most depending part of the wound ; and after
having enclosed them in a simple compress, cause them to be held there by
an assistant. Others cut both extremities close to the knot. Some bring them
out separately, and fix them by as many small morsels of diachylon upon the
corresponding points of the skin. Afterwards, a fine linen cloth covered with
cerate, and pierced full of holes, is placed over the whole extent of the bleed-
ing surface ; the edges of which are brought more or less forward, so as
to form a large hollow. This hollow is filled with picked lint, some regular
bats are placed above, two rather long compresses dispersed cross-wise should
embrace the whole extent of the stump, whilst a third envelops the circum-
ference : a bandage of convenient breadth and length then keeps the whole
in plaCe. Instead of applying a piece of fine linen immediately upon the
wound, as was done by Messrs. Boyer and Roux, and many others, some
• Although I employed myself on the subject of torsion, and experimented upon and
proposed it a longtime since (1826), yet, when M. Amussat also macje it the object of his
researches in 1829, 1 at first kept silence, hoping that that gentleman would arrive at
results completely conclusive ; now, however, as the opinions which I had then, and which
I hftve just now advanced, seem to flow naturally from all the works published upon the
sulyept, 1 deem myself authorized to promulgate it here without reserve ; entreating the
reader not to confound that exposition with the extravagant hopes which this hemostatic
resource has excited in the minds of sqme persons.
OPERAXrVE SURGERY. 16^
surgeon* still pursue the method of the past age, and till the solution of conti-
nuity with sponge, agaric, or lint, but surround the circumference with a fillet
or band of linen cut into points upon its external edge, and smeared with
cerate. The compress, pierced with holes, appears to me preferable. The
latter is easily turned over the edges of the wound, and there is no fear of
the lint or other parts of the dressing, contracting adhesions with the living
parts which have been divided. Finally, the second dressing may be per-
formed without painy and with the greatest facility whenever the operator
judges it advisable. The cross of >lalta, formerly in general use, has given
place to the oblong compresses, which are more easily applied and more
easily adapted to the forms of the different stumps. The operator must be
careful not to push them too forcibly towards the root of the member, for he
would not fiiil to crowd back the muscles and the skin, the retraction of w^hich
it is necessary rather to check than to favor. It is for the purpose of avoiding-
this retraction, and diminishing as much as possible the projection of the
bone which results from it, that Wiseman, and more particularly Louis,
recommends the application of the confining bandage from above downwards,
and not from below upward. In this particular I cannot too strongly recom
!nend the method followed by M.Richerand. The bandage is passed at first
once or twice round the trunk, it is then directed upon the root of the member
and brought by successive turns, moderately tight, to the level of the end of
the bone. The remainder of the dressing is conducted in the manner just
described. A new bandage, or the remainder of the first, serves to fix the
compresses by a second set of turns, and to maintain the whole in place. By
this means the muscles are prevented from easily retracting; the skin is
pushed forwards, and this method will moreover in a great measure prevent
the swelling of the stump,, the erysipelatous or phlegmonous infiammations of
which it often becomes the seat, and even phlebitis, which it is so necessary
to combat from the moment that it seems disposed to make its appearance.
B. Inwiediate Union. — Tho' method of bringing together the edges of the^
wound, of immediately closing it, does not appear to me to have originateci
earlier than^ the time of Alanson, or at the farthest than that of Gersdorf. It
was folloAved by Hay, and shortly afterwards by almost all the surgeons ot
Great Britain ; but it was viewed amongst us with a certain degree of re-
pugnance, except by Percy, who had occasion to use it frequently and to
prove its utility in the midst of camps. Pelletan, M. Larrey, &c. at first
strongly opposed it; but Messrs. Dubois, Richerand, Roux,Boyer,Dupuytren,
Delpech, and almost all the distinguished practitioners of Paris and the other
cities of France, concluded by adopting it in most cases. It appears, however,
that at the Hotel Dieu M. Dupuytren has found occasion to be less satisfied
with it than at first ; that at ta Charite M. Roux believed it his duty to
limit its application, and M. Lisfranc seldom makes use of it at La Pitie..
To unite by first intention, it is still more necessary than by the other
method that no foreign bodies should be left in the wound which it is possible
to extract. The operator begins therefore by carefully removing the clots
and the threads which are not indispensable, cleansing the sui-rounding parts
with a sponge, and by dryin* the whole with a soft linen clotb. This done,
he brings together as exactly as possible the divided parts, taking care to
leave no greater space between them at the bottom than at the edges of the
wounds While an assistant holds the parts in this state, the operator applies
the adhesive straps. By commencing with those of the middle, it will in
general be found more easy afterwards to apply the others. Three or four
are generally sufficient. It is a rule to leave a free space between them.
164 NEW ELEMENTS OF
instead of covering the whole of the stump. The longer thej are, all other
things being equal, the better they will hold, the less they fatigue the skin,
and the more perfectly they will attain the end proposed. To sustain their
action it is often useful to confine at the same tin.e upon the sides of the
wound, parallel to its greatest diameter, graduated compresses more or less
thick, or rolls of lint, either between the straps and the skin, or between
the bandage and the straps. This is the only way in most cases to prevent
the accumulation of fluids at the bottom of the wound, and to obtain a fair
and regular union.
If the threads have not been cut near the arteries, the operator brings them
out separately, and fixes them between the emplastic straps by means of small
ligature compresses.
Instead of the pinked bandage, or the pierced compress placed over the
whole anterior surface of the stump, some use a broad and thin bat of charpie
equably smeared with cerate. On this point everyone should be free to do
as he sees fit. The important point is to prevent the adhesion of the pieces
of the dressing to the parts about the wound. Dry charpie in soft bats is
then so disposed as to cover the sides and front of tlie stump. For this, two
or three bats are enough ; more would be rather hurtful than serviceable, from
the heat which would be cherished by them. The oblong compresses neces-
sarily vary in number or size according to the size of the stump. The middle
of each should fall just upon the wound, and the ends reach without stretching
to the root of the limb. That which is commonly laid across or around to fix
the others a little above their point of crossing, is very seldom of any real use,
A simple flexible bandage, rather narrow than too broad , finishes the dressing.
After naving carried this by circular turns from the end of the stump towards
the root of the limb, the operator brings it back in the same way to the wound,
in front of which M.Roux, among others, has a habit of crossinjK it several times,
both for the purpose of imitating that kind of cap which was formerly so much
employed, and to obtain an application of the bandage more regular and
more neat, but augmentin;^ the perpendicular compression at the expense of the
circular. As this piece ot prettiness may compromise the safety of the patient,
it should be omitted at least whenever there is reason to apprehend a stag-
nation of fluids in the depths of the wound.
Instead of plasters, which make what is called in the schools, the dry
suture, some operators employ the bloody suture, that is to say, they sew up
the wound. This method, to which Pigray, Wiseman, F. de Hilden, Sharp,
&c. had recourse in order to retain the skin, has been particularly eulogized
of late years, by Hey, M.Benedict of Breslau, and by M.Delpech, who affirms
that he has derived from it the greatest advantages; so that at Montpellier it
is scarcely ever dispensed with after amputations. The interrupted suture is
preferred in such cases, although the furrier's is equally convenient. For
greater security, and to ease the threads, the operator may, as recommended
by M.Delpech, place some small emplastic straps between them. If the em-
ployment of this kind of suture were not attended with great pain; if the
reunion of the integuments formed the most important part of the operation ;
if the plasters did not eft'ect the same purpose v/hen properly applied ; M.
D.'s method would doubtless long since have been adopted; the contrary
however being generally admitted to be the case, every thing seems to promise
that in future adhesive straps will continue to supply its place. ^ Seeing
that after the cure by first intention, the cicatrix, although linear 'at first
rarely fails to become puckered and to be surrounded with radiated wrinkles,
just as after secondary union, M.Roux has sometimes determined upon pro-
OPERATIVE SURGERY. 165
duciTig this wrinkling from the first by crossing the plasters in different
flirections, instead of placing them parallel with each other. But his first
iittempts having been unsuccessful, so skillful a surgeon has of course promptly
given up tliis practice.
W!ien the operator begins, like Louis, Alanson, and M. Richerand, by fixing
a long bandage round the trunk, and brings it down by successive turns to
'the base of tlie wound, it is upon this bandage that the straps must have their
hold ; and differently from the other pieces of linen, this should be changed
as seldom as possible. Kern, Klien, Walther, and the greater part of the
German surgeons considering the wound which results from an amputation
the same as any other recent and simple solution of continuity, use neither
lijit nor charpie, but just cover the stump with compresses kept continually
wet with cold water. This practice has found many imitators in England and
America, even among the surgeons in the hospitals, and I understand from
M. Castello, physician to the king, and professor in the university of Madrid,
that it has been for a long time followed throughout all Spain. In France it
has as yet found but a small number of partizans. This is to be regretted,
as, if 1 am not mistaken, the results obtained by foreigners have been most
satisfactory. Disencumbered of a heap of useless dressings, the stump is
kept tnuch more cool ; by preventing or moderating the inflammation to which
it is subject, we place the contiguous surfaces in the best possible condition
for immediate union, and the general reaction is reduced to a small matter.
The experiments which I have made, show nevertheless, that cold water,
although frequently useful, is not always without its inconveniences.
Appreciation of Immediate Union. — The ancient method of treating ampu-
tatory wounds is likely to produce a conical stump, necrosis of the bone,
exhaustion of the patient by the continuance of suppuration, and the most
lively pain after every dressing. Three, four, five, six, and even seven or
eight months, are sometimes required for cicatrization, and when accom-
plished, it occurs in so thin and imperfect a form that it is torn by the least
effort, and is always accompanied by a considerable deformity of ihe end of
the stump. By the new method, say Alanson, Messrs. Guthrie, Klein, &c.,
the patient sutlers incomparably less; the fever is always slight; no debili-
tating suppuration ensues; the stump remains firm, round, and well sup-
ported ; and at the end of eight, ten, fifteen, twenty, or thirty days, the cicatrix
becomes solid, and the patient is in a fit state to use an artificial limb. Out of
ninety-two soldiers who were treated in this manner by Percy upon the field
of battle, eighty-six were cured in twenty-six days ; and out of seventy,
Lucas lost only five. But while in France the chief of the military surgeons
advocated with so much ardor the practice of immediate reunion, the indi- ^^
vidual at the head of the civil practitioners applied himself to its proscription, ^jm^
Out of six patients, Pelletan saved only one; in all these cases there were^gp
effusions of blood and pus between the lips of the wound, and over the passage
of the vessels; and the only patient he cured, owed his recovery to an irrup-
tion of pw.s which burst the adhesion of the straps. " There is danger, then,"
says he, '* in closing a wound from which blood must be poured out, which
has an inclination to suppurate, whether on account of the ligatures which
irritate it, or because the bone, more or less affected by the action of the saw,
has necessarily a disposition to exfoliate." "The cure by first intention is
more prompt," says M. Gouraud, who adopts the objections^^of Pelletan, " but
it is more sure by immediate union: by prolonging itself, the suppuration
prepares the patient for the changes which take place throughout the body
after the loss of a considerable member; and whenever amputation is per-
166 NEW ELEMENTS Ot
formed for a disease of long standing, secondary union is tlj« orily method
that can be properly adopted." It may be replied, that if the accidents
mentioned by Pelletan frequently take place, such circumstances are rather
the result of a want of necessary precaution, than the inevitable conse-
3uences of the operation. That there may be some danger in stopping sud-
enly a profuse suppuration of old standing, in closing in eight days a wound
which results from the removal of a member which has for a long time per-
formed the office of a secretory organ, is very true ; but ought theseexceptions,
these feeble, and frequently questionable motives, to have weight against all
the perils of mediate reunion ?
In avoiding one extreme it is always necessary to guard against falling into
the other. It the bleeding surfaces can be easily brouglit into apposition; if
h«althy parts only remain in the stump, immediate reunion has immense
advantages, and ought certainly to be attempted. In contrary cases, the
operator is permitted to conduct himself otherwise, to confine himself to
bringing somewhat nearer together the lips of the wound after having placed
betv» cen them balls or tents of lint, eitiier bare, or with tiie interposition of
a linen cloth pierced with holes. It would be 'imprudent, even dangerous,
to persist in maintaining the contact, if in the 'course of three or four days
the blood or other fluids have escaped in sufficient quantity to hinder the
fair co-aptation of the parts from the bottom of the wound towards the edges.
It is then proper to allow an issue, large and W'ee^ to the fluids which have
accumulated behind the straps or the sutures, between the integuments or
the divided muscles; to cleanse gently the M'hole extent of the sinous or
fistulous passage, and afterwards to dress it with great care and tenderness,
and to think only of union by the second intention. By proceeding thus the
operator will obtain very frequently, if not always, a complete cicatrization
in the space of fifteen, twenty, or thirty days, even after the amputation of
the thigh, as I witnessed at UHopital de Perfectionnemeiit, during the period
of my service there with Messrs. Bougon and Roux.
C '^Combination of the two Methods. — In order to reconcile the two pre-
ceding methods, it would be easy to contrive a third, by applying to circular
amputation what is recommended by O'Halloran for the nap-operation. After
iuiving dressed the wound of the stump for eight or ten days without closing
it, until it has beconic mundified and regularly cove-red witli cellular granu-
lations of a vermilion color, there is nothing to prevent bringing together tiie
sides of the wound, and attempting to procure secondarily something like
immediate union. I have practised this metlwd a number of times with
success, particularly at the Hopital Sl.Antoine^ in the case of a patient whose
thigh had been amputated by M. Beauchere ; and again after amputations of
tlie fingers, the metacarpal and metatarsal bones, and of the legs and arms.
It has also been used with equal success by M. Roux, and has been extrava-
gantly praised by Paroisse. All the ligatures having come away, the wound
being cleansed, and the suppuration of a healthy character, it is generally easy
to put the edges of the wound in contact, either at once or by degrees, and
thus obtain co-aptation soon and without inconvenience. I am of opinion
then, that with very few exceptions it is best to aim at immediate reunion ;
but if unpleasant symptoms occur which are justly ascribable to this mode of
practice, the operator ought without hesitation to re-open the wound. 1 will
add, that the results of this method are much more under the influence of art
than those of secondary reunion, and that consequently they will be good
or bad according to the ability or inability of the practitioner; according as
he shall attach more or less importance to certain practical precautions which
OPERATIVE SUROERI^I'iiJd- 167
cannot be leamed from books, and of which only those who have used them
can appreciate the importance.
§ 3. — Consecutive Treatment,
Tlie patient having been returned to his bed, should be laid in the most
easy position, a hoop should be placed to support the weight of the covering
and to prevent it from bearing upon the stump, which reposes gently on a
cusliion or a folded cloth.
1st. The Position of the Stump. — This part is generally kept a little ele-
vated, so that the muscles may be relaxed, which according to the opinions
of some persons diminishes the determination of the i!aids towards the wound.
Some advantage is indeed derived from this posture in that respect, while
there is no suppuration. But when tills occurs, the posture in question
favors the inflammation of the intermuscular cellular substance, the donud-
ation of the bone, phlebitis, and the formation of abscesses ; the wisest plan
then, is to follow the advice of Hippocrates and of Alanson, and to place the
stump in a horizontal position, or even inclining downward, as soon at least
as suppuration is about to take place, and indeed in every instance where the
form of the member will admit of this arrangement.
2(1. Immediate Medication. — One or two spoonsful of wine may be useful
in diminishing the torpor or faintness wliich commonly follows the operation.
During the remainder of the day a gently antispasmodic anodyne is adminis-
tered by spoonsful, with the ^infusion of linden, violet, wild poppy, or ^ )me-
tJnng of that kind, sweetened with any kind of syrup, as a ptisan. Except
in cases where the patient is enfeebled by long suftering, the strictest diet is
to be strictly enforced.
3(1. The Regimen is, in other respects, the same as that enforced in acute
diseases, or after all the greater operations. When the patient is robusl or of
a sanguine constitution, and the operation has been performed for a recent
injury, if there has been no great effusion of blood, some, fearing a siulden
plethora, have said much of the importance of diminishing the quantity of the
fluids to prevent internal inflammations and the dangers of a general reaction.
Many practitioners in Germany, England, and America, pursue, however, an
opposite course. M. Koch, of Munich, administers to his patients from the
very first day, coffee, wine, and even food. M.Benedict contends, that bleeding
instead of preventing accidents is the means of favoring their occurrence.
It is, says he, the strongest subjects, men whose bodies are full of blood, that
most easily resist the operation of morbific causes, upon whom inflammations
are healed with the greatest facility. Consequently, the more you bleed them
the more you weaken them ? the more exposed are they to disease ; the inflam-
mations which they contract become the more dangerous and the more diffi-
cult to tpeat. This severe diet, these abundant evacuations of blood prescribed
by some operators, before and immediately after amputation, do not secure
any real advantage except where intervening diseases, inflammatory symptoms
manifest themselves upon the patient.
4th. The First Dressing should not take place in ordinary cases until
about the expiration of three or f(mr days, and sometimes even five or six,
according to the opinions of C. Magati', Monro, and others, and the pre-
sent practice in Spain. Patients in" general have a great dread of it, and
indeed it was formerly something for them to fear. No precaution was
taken to prevent tlie adherence of the lint or of the compresses to the bottom
or the edges of the wound ; and as it took place one or two days after the
fc
iC8
Xir;V KLEIflKNTS OF
(>{)erati()n, and cor.soijMeru! v !>< f.Me mi p|;U ration was established, it is no
Nvonder tliat l)ie recolit'ctioji of it has been preserved, and that it is even more
dreaded than amputation \Ue\i\ Oi» (l.is point it must be said that patients
have been agreeably disa[)pointed. Pieces of linen or bandages being covered
with cerate always render the separation of the other dressing more easy; at
the expiration of three or four days the humidity and the natural sweating
of the wound have on their part loosened the adhesions which might before have
required force to effect a separation, so that the first dressing does not inflict
more pain than those that follow. An assistant lays hold of the stump, which
he clasps and gently holds in his two hands, always being careful not to give it
the slightest jerk. The bandage, the compresses, being soaked with blood or
other fluids, commonly harden together, in drying, so that it is very often
more difficult to remove them. If then after having soaked them with lukewarm
v/ater, the operator does not succeed in their removal, it will be found neces-
sary for that purpose to apply the scissors.
These first pieces being detached, the tint is freely moistened, and the outer
layers oidy are removed while it yet adheres too "firmly. As soon as it is
exposed, the wound should be cleansed by gently dropping upon it lukewarm
water, and afterwards dried with apiece of old fine linen or pledgets of lint,
after which the dressings are reapplied as in the first instance, and are so
removed and renewed from day to day.
If immediate union is aimed at, and no especial accident occurs, this first
dressing is still further delayed. But in every instance, as it is in fact
but seldom that complete agglutination takes place in every point, it is equally
requisite to cleanse the stump on the third, fourth, or fifth day. If there is
no suppuration to be discovered ; if there is no threatening of the formation
of sinus or fistulous passages ; the lips of the incision should not be touched.
The most that can be allowed, is to remove one of the straps, and to imme-
diately replace it. In the contrary case, and when the plasters have become
loose, they should be renewed one after the other, and by gentle pressure the
purulent or other fluids should be assisted to escape. In order to detach
tliese bandages, the operator draws them successively from their extremities
\n the direction of the summit of the stump, from whence they should be
separated last, as there would be danger, in pulling them at one hold from
one Qm\ to the other, of destroying the adhesions which is yet too weak to
resist the slightest pull.
5th. The Ligatures seldom come away until the eighth or tenth day after
having divided by ulceration the artery which they surrounded; it would
consequently be useless to endeavor to withdraw them sooner; but when they
remain longer, it may be of some advantage to draw upon them gently at every
flressing. They are probably retained by some lamellar of fibrous substance
included with the artery in the knot. The more immediately they encircle
the artery, the sooner they v/ill come away. There is every reason to suppose
thi«t their presence in the wound is useless after the second or third day, and
that they might safely be removed after that period, if it could be done with
ease. I have seen them yield on the third and on the fourth day, without any
111 consc(juences, after amputation of the arm and of the leg. M.Beaufils of
Nancy, who holds that after the sixth day it is best to hasten their separation,
has contrived to subject them to a permanent tension to fulfill this indication,
which MM. Kluge and Lau, have since endeavored to establish as an axiom.
OPERATIVE SURGERY. 169
§ 4. Accidents.
The accidents to which the amputation of the limbs may give rise, are
serious and numerous ; some may occur at the moment of the operation, others
at a longer or shorter period after.
1st. During the Operation — Hemorrhage* — To patients in a weak state of
health, the loss of blood durinj^ the operation may cause immediate and real
danger ; it sometimes takes place before the operator has time to tie up the
vessels, either because the tourniquet has been relaxed or displaced, or because
the assistant does not well apply compression, or because the operator experi-
ences unusual difficulty in taking up the arteries. To prevent these inconve-
niences, it has been proposed to apply the ligature to the principal artery of
the limb before commencing the incision of the soft parts. M. Blandin,
reports an example of this practice, which is still followed at the hospital
" Beaujon," by M. Marjolin. Mr. Guthrie and some others have thought to
do better, in tying the arteries from time to time as they were cut. The art has
no other resource in this kind of accident than compression, mediate or
immediate, lateral or perpendicular, when the ligature cannot be applied.
But there is still another species of hemorrhage which does not require tlie
same kind of remedy; I mean that which comes from the veins, a kind of
hemorrhage which is very abundant with some persons, and is even some-
times very troublesome. It is caused by the provisional compression pre-
venting the blood from returning in the direction of the trunk, or else to some
defect in the respiration. In order to stop the effusion, some persons advise
to tie the principal vein; Monro, Bloomfield, Hey, and Guthrie, are of this
opinion. Amongst ourselves the practice is generally different. We remove
at once every thing which may impede the course of the blood towards the
heart. We induce the patient to make long inspirations, and the hemorrhage
is almost instantly arrested.
The syncopes which result from hemorrhage, pain, or the state of excite-
ment into which the operation sometimes throws the patient, require little
more than moral means. A spoonful of wine, when the symptoms are fore-
seen, cold water, vinegar, or cologne water sprinkled on the face, or applied
to the nose, and all the other remedies generally used in such cases, do not
require more particular mention here. It is not unfrequently the case, that
immediately after the separation of the limb the stump is seized with a tremor
■which it is very difficult to allay, or with a species of convulsive or spas-
modic movement which requires the greatest attention. At such a moment
we should attract as forcibly as possible the attention of the patient, and
rouse his courage ; we intreat him to hold for himself the root of his limb,
unless it should be thought better that an assistant should clasp it firmly with
both hands until the dressing is completed : this state generally remains but
a few minutes; if it seems, however, disposed to continue longer, the stump
when placed upon the bed should be fixed by a cloth or napkin folded in the
manner of a cravat. This is a juncture at which opiates are particularly indi-
cated.
2d. After the Operation, the accident to which the patient is most liable
is that of hemorrhage, which happens either because some important arteries
have been left untied, or because one or more of the ligatures have become
relaxed, but more frequently than is often believed from a species of imi-
tative exhalation proceeding from the surfaces of the wound. After the third
or fourth day, hemorrhage rarely occurs but in this way, unless the ligaturc-i
22
170 NEW ELEMENTS OF
should liave cut some of the arteries by ulceration : after the eighth or tenth
day it is difficult to account for it, Bromfield, Guthrie, and other practitioners,
have seen it appear after a delay of three weeks, a month, or even a longer
period. There is reported an observation of a patient operated upon by
M. Roux, in whose case hemorrhage did not appear until after the expiration
of two months. The inflammation of which the vascular tunics become the
seat, in the thickness of the stump, the suppuration which surrounds them at
the bottom of fistulous passages, can alone account for this species of perfora-
tion. Hey and Hennen contend that consecutive hemorrhage is frequently
caused by the skin retracting and compressing circularly the subjacent tis-
sues, particularly the venous canals, and that it is by th^ vessels of this
latter class that the blood is permitted to escape. This opinion seems to me
any thing but well founded. When the blood escapes through the medium
of the veins (according to Ponteau), it is to be attributed to the unequal or
too forcible compression exerted by the bandage upon the stump, rather than
to the contraction of the skin. It is then sufficient to remove the dressings
and to re-'i^pply them more methodically, in order to immediately remedy the
accident. Another species of hemorrhage which appears to have been first
eradicated by M. Gouraud, is that which comes from the bones in case of
necrosis 5 the blood is perceived at each dressing to arise between the living
and the dead tissue ; compression or obstruction will not arrest its progress,
nothing in fact but the removal of the affected organ. Congestion, or a sliglit
inflammation of the stump, are causes of hemorrhage which may be checked
in diff*erent ways. Ist. By frequently soaking all the dressings anew with cold
water. 2d. By applying the tourniquet or the garot to the principal artery
of the part. After having found tliese means insufficient, it is then proper to
remove the dressings, in oi^er to seek for and to tie the vessel which gives
rise to the effusion. As it is but seldom that after the first twenty-four hours
this last method of treatment succeeds, in consequence of the changes which
have taken place over the v/hole extent of the bleeding surface, there is then
nothing to be done except to applj agaric or sponge upon the point from
whence the blood exudes, as advised by White and Brossard, or to stuff the
wound in anyway whatever until the hemorrhage is arrested; to use the ma-
chine invented by Petitj to compress the open vessels immediately by means
of pellets of lint or of linen sprinkled over with colophonyjby the fingers of
the assistants, which are successively relieved for the space of some days, or
what is much better when it can be done, to discover the principal artery and
to tie it above the wound, as Messrs. Roux, Dupuytren, Delpech, Somme, Ghi-
della, and Arnel have done with success. Yet in a case cited by Blandin, and
some others mentioned by Mr. Guthrie, this ligature, after the manner of Anel,
has failed in stopping the effusion of the blood, and the patient has finally suc-
cumbed. If the open vessel should be surrounded by soft parts, the ope-
rator may cut round its circumference with a single sweep of the point of a
bistoury at the bottom of the wound, and close it immediately by placing
a thread in the circle of the incision, as M. Sanson has once done with
success.
It would be wrong to count as a hemorrhage that sweating which rarely
fails to soak through, or to affect in some degree the dressings, the linen, and
even sometimes the whole thickness of the cushions, after the first or second
day. Evep when it is pure blood and not a sanguineo-serous effusion, there
is no occasion for alarm unless the patient have experienced from it some
degree of weakness. As a general rule, while the pulse keeps its force, and
the paleness of the countenance is not increased, cold ablutions and the tour-
OPERATfVE SURGERY. 1ft
niquet will suffice, if it should be thought proper to make any application
whatever.
Conical figure of the Stump. — This, which was formerly the almost inevi-
table result of amputation, has, since the works of J. L. Petit and of Louis,
become extremely rare. By immediate union, it is almost always prevented.
It is now only after cure by suppuration that it sometimes occurs. As it is
owing entirely to the retraction of the muscles, it depends upon the operator
to avoid it, unless the healing of the wound have been retarded by some
unforeseen obstacle. The processes of Petit, Brunninghausen and others, which
consist in bringing only the skin over the surface of the stump, are considered
as less efficacious than those of Louis, of Alanson, Desault, and of Dupuy-
tren, or all those in fine, which consist in cutting upon the bone the adherent
muscles farther up than those which are loose; but this is a question to be
hereafter considered.
Upon this subject it must not be forgotten that the muscles retract much
more upon some subjects than upon others, in proportion as they may be
formed of longer fibres; may have been divided farther from their point of
origin ; may have been more irritated, be slower in reuniting, or in incorporating
themselves with the cicatrix; and we should not confound their primitive
with their secondary retraction.
The contraction whi<:h immediately follows their division is not the only
one which is observed. The muscles are frequently seen, and particularly
upon persons of much strength or fullness of make at the time of operating,
but who have become enfeebled soon after — they are frequently seen, as I
have said, to retire deeply into the sheaths, to abandon the bones which they
have previously entirely covered, and to ^ive a conical form to the stump
which had presented a deep hollow at the time of the first dressing. So that
the first division should be made so much farther from the last as the limb is
larger, and the amputation too should be performed further from its root in
the same proportion.
After the operation, the retraction should be opposed by applying to the
stump the moderately compressive bandage of the ancients, as improved by
Alanson, Louis, Richerand, and others ; taking care that instead of having a
tendency to force the flesh backwards, every part of the dressings shall, on the
contrary, operate so as to bring it forwards. The wound should be dressed
as gently as possible, avoiding every thing which might irritate, favor suppu-
ration, or delay the union ; and the part should be placed in a state between
flexion and extension, so that all the muscles may be somewhat relaxed.
From whatever cause it may arise, the projection of the bone is always an
unfortunate circumstance; when it is but slight, and not accompanied by
denudation, according to the practice of M. Gouraud it should not bo touched.
Nature will perfect her own work, and will finally displace the cicatrix, so
as to bring the skin over the end of the stump.
Exfoliation, which was long considered an inevitable consequence of ampu-
tation, is now counted an unfortunate accident. As it is extremely slow in
its progress, requiring thirty, forty, or perhaps sixty days to complete its
work, it should seldom be left to the unassisted eftbrts of nature. The hot
iron or potential cautery, the nitrate of mercury, for instance, which were
until of late frequently employed, and that even by Sabatier, have scarcely
any eft'ect in hastening the process.
It is much better to remain contented with slight eff()rts with the forceps,
repeated at every dressing, upon the osseous eschar, as soon as it becomes
movable. It is well to remark, moreover, that the eschar will frequently
172 NEW ELEMENTS OF
disappear without any apparent exfoliation. An adult, whose leg had been
amputated by M. Beauchene, was affected by necrosis of the angle of the tibia,
of which we satisfied ourselves by means of the probe. The wound closed
over it, but a small abscess betrayed itself about a month afterwards ; I opened
it and a fluid and reddish pus issued forth, but the necrosis no longer existed,
and the fistula soon finally healed. In another case where the whole stump
had suppurated, I saw for a long time the extremities of the tibia and fibula
of a lime-like whiteness, slightly tinged with yellow, jagged, sonorous, and,
in short, completely dead. By degrees they were lost in the thickness of
the flesh, the cicatrization was affected, and in the space of four months the
cure was complete.
Removal of the dead bone, which was the subject of so much debate in the
ancient academy, is given by Sabatier as a simple and easy operation with-
out pain ; by others, as a second amputation, often more dangerous than the
first. Wlien this operation is resorted to, it must be performed high enough
to avoid the necessity of its repetition; high enough to secure the patient
against a recurrence of the projection. It is easy to see, that if the integu-
ments and the superficial muscles are to be much removed from the end of
the bone, the operation must be extremely painful, whilst, if nothing is to be
done but to saw off the superfluous part at a few lines above the necrosis, the
operation will be one of trifling importance.
Inflammation sometimes, and particularly after immediate union, seizes
upon the periosteum, which suppurates and peels off. The bone thus denuded,
seldom fails to mortify through either the whole or a part of its thickness.
At other times, the necrosis begins in the tissue of the organ itself, and the
danger of the accident is then increased. The first duty, in such a case, is
to open with the bistoury a free passage for the escape of the pus, or other
morbid fluids, and endeavor to restrain the extension of the disease by ajiply-
ing an expulsive compression from the root of the stump down to the wouncl.
Then we must wait the exfoliation, or else when the disease has ceased to
extend, the dead bone is cut off, or amputation is again performed at a higher
point, as in the remedy for conicity.
3d. The Hospital Putrefaction, which often follows amputation, is one of the
most unfortunate complications which can possibly occur. When it attacks
the stump and invades to a considerable extent the muscles of the integu-
ments, when the bone is denuded, and when topical applications and among
them caustics have been essayed in vain, then amputation above the next
articulation, or if that is not practicable, simply above the limits of the affected
part, is our last resource. M. Gouraud has obtained many unexpected cures
in the army, and in the Hospital of Tours, where I have myself witnessed
them. Messrs. Percy, Willaume, and Desruelles, have also followed the
practice, and I do not hesitate to recommend it in the cases which I have
defined.
4th. The Inflammatory Swelling of the Stump sometimes presents itself under
the form of a simple erysipelas, and sometimes with the characters of erysipe-
latous phlegmon. In the first case if the skin alone is affected, the emplastic
straps are often the cause, either on account of their being too ti^ht, or be-
cause they contain too great a proportion of irritating matters. It is enough,
then to remove them, and to envelope the inflamed surface for some days with
emollient cataplasms. In the second case the accident becomes more serious,
and requires more particular attention. The inflammation is quickly carried to
a great extent; the skin and the muscles are soon dissected by pus; the subcu-
taneous tissue, the deepest cellular interstices sometimes mortify and come
OPERATIVE SURGERY. 173
ftwaj in sloughs, an ataxic or adynamic fever arises, and puts the patient in
'he greatest danger. Secondary reunion is seldom attended with similar acci-
lents. This is, therefore, one of the best founded objections which can be
idduced against primitive coaptation.
From their first onset, these symptoms should be combated with energy.
They are sometimes calmed by laying the entire surface of the wound bare
30 as to dress it flat, or by covering the stump with leeches, and afterwards
with cataplasms ; but when such means fail of success, or it is too late to
make the application, the most efficacious remedy which is known to me is
that of deep and multiplied incisions. In 1828, at the close of summer, I
had occasion to try the flap method in amputating the leg; the whole thick-
ness of the stump soon became the seat of inflammation ; erysipelas and
purulent collections already occupied the inferior third of the thigh; stupor
and other adynamic symptoms advanced with frightful rapidity. I thought
the patient lost, beyond all hope. M. Beauchene, who thought differently,
made eight or ten incisions in the diff'erent inflamed parts of the skin. The
symptoms from that time began to retrograde, and the patient recovered,
much to my astonishment I must confess. Against that erysipelas of a grey-
ish tint which so often terminates in gangrene after amputation, M.Larrey
employs the actual cautery. The hot iron being applied with some force in
such a form as to imitate the branches of the fern or the nerves of a laurel
leaf, for example, or any other figure, upon the inflamed points, produces
sometimes most wonderful effects, the extraordinary results of which I have
myself witnessed at the *' Hopital de la garde.^^
If the disease has become local after having given rise to numerous general
symptoms, there sometimes results a denudation of the bone or fistulous
passages, a pointed stump, which can only be remedied by a second amputation.
"Experience has taught me," says Gouraud, " that the patient endures the
amputation of the stump better than that of the limb, and that the first has a
greater chance of success than the second ; out of ten individuals upon whom
1 operated in this way in 1814 and 1815, nine were cured." Instead of
aff'ecting the whole stump, the inflammation confines itself in some cases to
the cellular tissue about the vessels, and particularly about the subcutaneous
veins ; it then soon forms for itself in the course of these vessels small purulent
spots or abscesses which should be opened at an early period, if antiphlogistics ,
or compression have proved unable to prevent them.
5th. Phlebitis. — The veins often become inflamed, either separately or
with the surrounding parts. Here, as in every other case, phlebitis is
extremely dangerous. Hunter, Abernethy, Travers, and others, proved it
long since. The symptoms of adynamia, putridity, and of ataxia, to which
it very soon gives rise, are almost always followed by death, so that it is one
of the most formidable accidents which can possibly occur after amputation.
The dangers with which it is accompanied, attributed until quite lately to
the propagation of the inflammation from the stump towards the heart, in
fact depend entirely upon another cause. The mixture of pus with the
blood, and its transportation through all the organs, present a much more
satisfactory explanation, as I believe I was the first formally to express in
1824, 1825, 1826, and particularly in 1827; and as has been since proved by
Messrs. Marechal,Reynaud of Marseilles, Dance, Legallois, Arnott, Blandin,
and others ; an explanation of which several of the ancients had some vague
notion. Purulent resorption is another accident of which the dangerous
results are exactly similiar.* The recent researches begun by M. Monod,
^' ♦ See introduction.
174 NEW ELEMENTS OF
and continued by M. Rejnaud and others, go to prove that the inflammation
of the medullary tissue of the bones, of their proper veins, and of their spongy
substance, participate also in the production of the symptoms generally attri-
buted to phlebitis or the resorption of pus ; but this question demands further
investigation, and if decided in the affirmative, would make entirely for ampu-
tations in the articulation, by exposing more fully the dangers of amputation
in the body of the limbs.
6th. Cystitis. — ** It is often necessary," says M. Gouraud, "to use the
sound upon the subjects of amputation," and many observers have made the
same remark. Whatever may be the primitive cause, cystitis is no very rare
occurrence after amputation, particularly of tlie abdominal extremities. It
should be apprehended at the least symptom of any affection about the uri-
nary passages. I need not say that vesications should be proscribed when
this affection is threatened ; but M. Blandin is certainly mistaken in con-
necting it with the use of this therapeutic agent, for it is observed when no
preparation of cantharides has been used, as I have myself seen in the
case of a female, upon whom amputation of the thigh had been performed by
M. Roux, in 1826. For more ample details upon the accidents which have
been here passed in review, upon tetanus, and every other disease which may
complicate the results of amputation, I can only refer to the treatises on
pathology, properly so called.
Changes which take place in the Organic State of the Subjects of Amputation,
After the removal of a limb, changes sometimes of a very remarkable nature
occur in the person of the subject known to all surgeons, and of late well
described by Messrs. Gouraud, Cloquet, and others. Some affect the stump,
others the constitution in general.
1st. In the Stump. — The muscles, the cellular tissue, the aponeurosis, the
tendons, the bones themselves, undergo at the place of section a transform-
ation of such a character, that all the parts are confounded in attaching them-
selves to the cicatrix, and constitute there nothing but lamallae or fibrous
cords, more or less dense, and more or less distinct. Afterwards the stump,
which had at first become meagre, becomes the seat of a more vigorous nutri-
tive action, increases in size, and at a longer or shorter period puts itself in
this respect upon a level witli the root of the other limb.
2d. In the rest of the Economy. — The subjects of amputation attain a remark-
able embonpoint, acquire an increase of energy in the organs of digestion,
of circulation, and of reproduction; the fluids of life being obliged to move
in a more contracted circle, increase the activity of all the functions. They
tend to induce the characteristics of the sanguine temperament. The
sanative efforts of nature to remedy the plethora of the economy, manifest
themselves according to age or sex, by epistaxis, hemorrhoides, more abun-
dant menstruation, frequent stools, transpiration, and more copious secretions.
Garengeot advises, that in order to prevent plethora and a revulsion of blood,
bleeding should be practised from time to time upon those who have been
subjects of amputation ; that at least one-fourth part of their customary nou-
rishment should be taken off during the first year, and the subject should
abstain from all violent exercises. A soldier of the army of the eastern
Pyrenees had both thighs amputated, and recovered. The activity of all the
viscera, and especially of the stomach, increased in a singular decree; in a
short time this man became extremely fleshy, the consequences ot which it
was difficult to calculate. The dejections became more frequent without
any perturbation of the bowels, but the immobility to which this double muti-
lation subjected him, produced a diseased plethora. A species of carriage
OFERATIVE SURGERY. 175
was procured for him, but this passive movement did more harm than good,
for it favored the digestion more than transpiration or the other excretions.
This unfortunate man finally sunk under the burden of sanguineous plethora.
**I have made these observations by hundreds," says Mr. Gouraud, "and
they certainly appeared to me to be worthy of the attention of the faculty."
I have myself seen two very marked instances of a similar character.
Art, 2. — The Flap Operation,
History, — Amputation by flaps seems to be ascribed by Sprengel and Gag-
nier, to Celsus, Maggi, and others of the older surgeons, such as Pare and
Hilden, and was not,, as is generally believed, proposed for the first time by
Lowdham in his letter addressed to Young, and published in 1679. We shall
see presently that Leonides and Heliodorus have clearly described it. It con-
sists in cutting out of the soft parts one or more flaps, which permit the wound
to be immediately and completely closed. After Lowdham, this method was
extravagantly praised, and differently modified by Verduin, of Amsterdam, in
1669 ; by Sabourin, of Geneva, in 1702; by Morand, De la Faye, Garengeot,
before the middle of the last century. It was opposed by Koenerding, a
countryman of Verduin, by Heister, and many others, but was soon defended
by P. Massuet, Le Dran, Ravaton, Vermale, Quesnay, and others. Since
then O'Halloran, Messrs. Dupuytren, Roux, Guthrie, Klein, Kern, Langen-
beck, Larrey, Lisfranc, and a multitude of other surgeons, have had recourse
to it ; so that its history presents really two distinct epochs, the one compre-
hending all that was said of it during the last century, and the other belonging
particularly to the present time.
Appreciation. — Lowdham holds that this method is more prompt, less dan-
gerous, that it occasions less risk of tetanus or hemorrhage than circular ampu-
tation, that it renders the ligature of the vessels useless, prevents exfoliation,
obtains a speedy cure, and makes very easy the application of an artificial limb.
Of these advantages there are several which have not been confirmed by expe-
rience. In the first place it cannot be perceived how it can be less painful
than the circular method, or can more surely prevent tetanus. The exfo-
liation of the bone is a very rare thing; instead of being frequent, as it was
then thought, and as the preventive means are not to be applied to the stump
itself, it is, in this respect, a matter of indifference whether the amputation
has been performed by one method or the other. Finally, it is easy to see
that it does not dispense with the ligature of the vessels, and that the incision
scarcely ever cicatrizes without suppurating for a longer or shorter period.
Immediate reunion is an incontestable advantage; and if the improvements
in the circular method did not permit the attainment of the same end in
the majority of cases, there is no doubt that amputation by flaps would, at
this day be generally preferred. It must also be confessed, that it makes it
easy to avoid the protrusion of the bone, the pointed shape of the stump, and
that it preserves enough of the soft parts to close without dragging the widest
and deepest wounds.
Manual. — The flap operation is performed in two general ways, from
without inwards or from within outwards. In the one, the incision is carried
from the skin towards the bones, whilst in the other the operator commences
by plunging the knife through the member so as to cut the flap from its root
towards its free border. If the first method is more regular and more sure, the
second is much more rapid and more brilliant. In operating in the first of these
juodes, it is well to begin by dividing the integuments at the first stroke, and
176 »EW EL^MfeNTS OJF
causing these to be drawn back by an assistant, to effect at a second stroke
the division of the muscles a little higher up. By this mode it is easy to
give to the flaps the desired form and dimensions ; but the operation is di-
vided into stages, and thus made less rapid.
In piercing at first the thickness of the limb, the point of the instrument
is liable to contact with the bone, and often attacks organs which it might
be best to preserve, divides irregularly some tissues which it is important to
cut smoothly, and does not always cut the flaps ias thick as is necessary for
the attainment of the end proposed. This mode of operating has in our days
found numerous partisans and able defenders, but it is hardly ever adopted
any more than the preceding, except in amputations at the joints* On the
whole, it appears to me that too much value has been accorded to the flap
method. The wound which results necessarily presents a more extended
surface than if it had been circular. The muscles which the operator is so
careful to preserve, expose him to several inconveniences. If inflammation
seizes them, they suppurate very profusely, imbibe the fluids like a sponge, and
favor, in a very high degree, purulent resorption and phlebitis. And again,
they seldom attach themselves over the extremity of the stump in the centre
of the cicatrix. After all, it is always the skin that corresponds with the
osseous protrusions which the semilunar form of the flaps, by the retraction
of the angles of the wound, favors more than any other method. For the rest,
it offers a certain number of distinct varieties. Lowdham, Verduin, Sabourin,
Guthrie, and Grsefe, content themselves with a single flap, which they apply
against the bleeding surface. Vermale advises to make a flap on each side,
and to form them by thrusting the point of the knife upon the part of the bone
where the saw is to be applied. In order to avoid deception with regard to
their length, he advises before commencing to mark with a red thread the
points of departure and of termination. Ravaton and Bell divide the skin
and the whole thickness of the muscles circularly, at the first stroke of the
knife ; another incision, which falls upon the bone parallel to its axis behind
and before, serves then to separate two flaps, which are immediately dis-
sected and drawn up. The procedure of Vermale is now almost the only
one which is followed, even for the formation of a single flap. The practice
of Ravaton should by no means be imitated. The circular division first made
is completely wasted. The flaps thus squarely cut are too thick towards the
end, and retard considerably the direct reunion.
Two flaps should always be preferred whenever it is possible to give them
a size and thickness nearly equal ; but if this cannot be effected, it is much
better to have but one. In this latter case it is required that the flaps, in
order to close the wound, should be of considerable length, that it should be
bent nearly at a right angle, that it should be subjected to a pressure, and to
tractions which should be very likely to compromise the success of the ope-
ration.
We shall see, in describing amputations in particular, the cases in which
this method of operating is inapplicable.
Art. Z.-^The Oval Method.
This method is less ancient than the two preceding* It was described at
the commencement of the present century by M. Chasley, Messrs. Langen-
beck, Beclard, Guthrie, and Richerand, as applicable to certain particular
amputations, but it was not really generalized until the year 1827, by M.
Scoutetten. According to his opinion, its principal advantage is that of
OPERATIVE SURGERY. Iff
always permitting the incision to be made from without mWards, from the
superficial towards the deeper parts, as in the circular method, and of pre-
serving enough of the flesh to bring the lips of the wound together as easily
as in the flap method ; so that, says he, it places itself between these two,
and is, so to speak, a link between them. It is certain, that by the oval
method a neat and regular division is obtained, and that most frequently
enough of the tissues may be preserved to justify an attempt at direct reunion,
and that there are but few points of the members to which it is not appli-
cable.
Its distinct character is to present an incision of an ovoid form, already
recommended by Lassus, in 1793 ; by M. Chasley, in 1803 and 1804 ; by M.
Langenbeck, in 1809 ; and from which Mr. Scoutetten derived the title which
I have preserved for it. It is performed in two ways, scarcely distinguish-
able the one from the other. In the first and the oldest mode, the operator
begins by describing a triangular flap in the form of a V inverted, a little
below the passage where it is necessary to apply the saw, or to disarticulate
the bone. After having turned down the apex of this triangle, and raised the
two lips of the incision, he passes, by penetrating the joint either from above
to below or from one side to the other, behind the bone, grazing its lower
surface, and finishes by reuniting the two previous incisions at the base of V,
where the vessels had been preserved. M. Scoutetten prefers giving his
incision from the first a form completely oval, being careful, in passing under
the vascular and nervous lash or upon the part which is to form the greater
extremity of the oval, to divide only the integuments. This is no otherwise
important than as giving a little more regularity to the incision.
Some persons have advised a combination of these methods in certain cases,
for the purpose of profiting by the advantage of the one, and of avoiding the
inconveniences of the others. It is thus that O'Halloran adopts the fol-
lowing modification, which in his opinion should command every suffrage in
favor of the method of Lowdham. Instead of applying compression to sup-
press hemorrhage, he advises, as also does Garengeot, to tie the arteries care-
fully, and, to be more certain that no serious accidents may happen on the part
of the stump, he advises to dress the wound flat, and let it suppurate for eight
or twelve days, then to raise it as soon as it is covered with cellular granu-
lations, and adapt it carefully to the rest of the wound. White and M. Pa-
roisse declare that they have tested this modification in practice a great
number of times with the most favorable results, and I have come to the con-
clusion, from the experiments which I made of it under the head of secondary
direct unions, that it has been but badly appreciated amongst us, and that
in a multitude of cases it holds out the most undeniable advantages. What
O'Halloran has added to the procedure of Lowdham, Beclard has advised for
that of Vermale — when the flaps are formed of tendinous parts, of fibrous
sheaths, and of synovial sacs. After having cut the skin circularly, instead
of incising the other soft parts in the same manner, M. J. Cloquet has thought
that in certain cases it would be better to pass the knife between them and
the bones, and to cut outwards as in the flap method. M. Dupuytren has
applied the same modification to the flap operation.
B. — Amputations in Contiguity,
History, — The perusal of the works of Hippocrates teaches that amputation
at the joint was often practised by the ancients. Galen and Heliodorus speak
of it in the most explicit terms. Even the Arabs were not ignorant of it
23
178 NEW ELEMENTS OF
Sprengel is evidently mistaken, when he asserts that it had not been men-
tioned from the time of the Grecian writers up to that of Munnicks. Guy de
Chauliac formally avers, that "if corruption reaches to near the joint, the
member should be cut off in the joint itself with a razor or other instrument,
without using the saw." Pare has not passed it by in silence. F. de Hilden
treats of it as a common method, and Pigray expresses himself thus on the same
subject : *• Some persons make a difficulty of cutting into the joint or near it,
on account of the nervous parts, but the danger is not so great. I have seen
many cases of it which turned out well." The efforts of Le Dran, of Morand,
of Heister, of Brasdor, and of Hoin, have only brought it again into vogue, by
doing away the prejudices with which it had been surrounded by the physio-
logy of the middle ages. It is practised, like amputation in the continuity,
by the three principal methods, but most commonly by the flap method and
by the oval. We shall see, however, that the circular method is quite appli-
cable to it, and that it is even preferable in a good number of cases.
Appreciation.'— The advantages of disarticulation are, that it is more prompt
and more easy of execution than the preceding, that it does n6t require the
division of the bones, facilitates an immediate reunion, and admits of the
preservation of a greater length to the limb. It is attended, however, with
the inconvenience of laying bare large osseous, or cartilaginous surfaces, at
least in most cases ; requirmg the use of instruments on me thickest points
of the skeleton, and those which are least abundantly furnished with soft
parts ; compelling us frequently to make use of tendinous or synovial tissues
to close the wound ; of presenting a solution of continuity perhaps, a little
less regular; but it is not true, as it was long thought, that, all other things
being equal, it exposes more than amputation in continuity, to nervous affec-
tions, to tetanus, to abscesses, to purulent fistulse, and to the symptoms of
general reaction, although these phenomena may sometimes have occurred
after it. It is executed with an inconsiderable number of instruments, and
does not require such complicated dressings as the other method. A knife,
or the simple bistoury is almost always sufficient for every step of the ope-
ration; the conicity of the stump, the projection of the bones, tne retraction
of the muscles, are the less to be feared, as the soft parts are scarcely dis-
placed, the adhesion of the flaps is easily obtained, and inflammation does not
develop itself to a greater degree than is necessary to determine a direct
union.
As the division passes through only the skin, the cellular or fibrous tissues,
and some of the muscular attachments, inflammation, abscess, or general re-
action are generally less to be feared; although large in appearance, the
wound is in reality but small in extent, because the cartilaginous crusts
which form the bottom being insensible and inert, perform no part in the pro-
cess of inflammation or of suppuration.
The fears entertained by the surgeons of the last century, of wounding the
diathrodial cartilages, of exposing them to the air, or of touching them with
the instrument, are at the present day exploded. Instead of so many pre-
cautions heretofore recommended in order to avoid the articular surface which
rests at the bottom of the wound, many of the moderns have even gone so
far as to recommend wounding it on purpose. M. Gensoul,for example, is
of opinion with Richter, that by cutting it off with the point of the knife
you multiply the chances of cicatrization in the first intention. This prac-
tice, which IS also adopted by some of the Parisian surgeons, and which is
accompanied with no inconvenience, yet appears to rest upon a reason the
importance of which is by no means proved. In fact, it is inaccurate tG say.
OPERATIVE SURGERY. 17^
with Beclard and many others, that after amputation in continuity, the
smooth front of the cartilage does not unite itself with the flap, that it remains
free even after a final cure, unless inflammation have been by some means or
the other, excited in it. Whether the instrument has touched it or not, it
contracts nevertheless, and that very quickly, firm adhesions with the tissues
which cover it. If the agglutination is not immediate, the cartilage is some-
times pushed forward by cellular granulations which arise from the bone
behind it, and detaches itself in small parcels, sometimes in large flakes,
sometimes in the formof a shell, and exposes a vermilion wound, which cica-
trizes easily. In a contrary case it does not at first sensibly change its
aspect ; it only loses its polish, and becomes rugous 5 but a molecular action
is sure to develop itself, to sap it insensibly, and to cause its entire disap-
pearance. It is a true epidermis of the bone, a simple **anhiste" stratum,
and cannot retain its distinctive characters longer than the articular move-
ments are kept up. As soon as any of the living tissues rest upon it, the
vitality of the bones expel or destroy it in creating the cellulo-fibrous stratum
which forms the basis of every perfect cicatrix. In which ever way the ope-
ration is performed, the tendons, aponeurosis, nerves, and vessels, at last fix
themselves firmly upon the extremity of the stump, so that the patient can
move it with as much ease as before the operation.
When the articulation is surrounded by a large capsule, it is well to remove it
as completely as possible with the bone, without, however, in any case disturbing
that portion which remains. Instead of the tendons being left to hang out-
side of the incision they should on the contrary be cut as deeply as possible,
in order that their presence may not impede the direct reunion. The incision
of the fibrous or synovial sheaths, advised by Garengeot and Bertrandi, with
a view to prevent inflammation or to oppose the formation of purulent fistulae,
is entirely useless, and should not be practised without particular indication.
The fistulae which sometimes follow in the train of amputations at the joints,
are formed either because some point of the cartilaginous surface which has
not exfoliated nor united with the flap of soft parts, continues to exhale
synovia; or perhaps because one or several of the tendinous sheaths or bursae
yvhich have not closed, furnish fluids of a similar kind. Compression, irritat-
ing injections, caustics, &c. easily heal them, and they are seldom followed
by any unpleasant symptom. For the rest, amputations in continuity are not
always free from accidents of the same kind. On the whole then, the extir-
pation of limbs is not more dangerous than amputation properly so called.
CHAPTER II.
AMPUTATIONS IN PARTICULAR.
SECTION I.
Thoracic Extremity, — The superior extremities, which are so much exposed
by constant use and their relations to external agents, to contract all kinds
of lesion, frequently require amputation. It should here be held as a general
180 NEW ELEMENTS OF
principle, that as little should be removed as possible. The smallest portion
which can be preserved rarely fails to be useful. Thus we amputate sepa-
rately, the fingers, the different bones of the metacarpus, the hand itself, the
wrist, the fore-arm in its continuity and at its articulation, the arm at the
different points of its length and at its union with the shoulder, and the
shoulder itself.
Art. 1. — Finger9»
The amputation of the fingers, an operation scarcely recognized by the
ancients, is now performed frequently and in many different ways, whether
the operation is confined to the removal of one of their phalanges, or whether
they are removed entirely, whether amputation is performed in the continuity
of the bones which compose them, or whether* you prefer to disarticulate them.
Aiuitomical Remarks. — The fingers have for the basis of their structure
three osseous pieces, which are articulated by ginglymas for the two anterior
phalanges, and by enarthrosis for the metacarpal phalanx. They further
consist of tendons, fibrous sheaths, synovial sacs, arteries, voluminous nerves,
and a cutaneous stratum remarkable in the appearance of its anterior portion.
On their palmar face are found the two flexor tendons and the fibro-synovial
canal in which they glide. The one is attached to the articular tuber of the last
phalanx, and by a fibrous cord to the metacarpal phalanx. The two strands of
the second attach themselves to the sides of the middle phalanx. As all these
tendons meet in the hollow of the hand in order to reach the wrist or the
fore-arm, there can be nothing more dangerous than the inflammation of their
sheaths after the amputation of the fingers. The cellular tissue, gathered to
the front in the form of a cushion, directs to this quarter in the search of soft
parts to cover the stump after the operation. Their dorsal face being more
round renders it impossible to cut upon it a flap of proper size or thickness.
The two arteries which run along their sides lie too near to the bone to let
compression be substituted for the ligature. The two phalangeal articulations
present this circumstance worthy ot remark, that being held by two very
strong lateral ligaments, and in the rear by firm tendons, they cannot be passed
through without certain precautions. The pulley in which they terminate,
and the small cavities, separated by a ridge which may be found upon the
posterior extremity of these two phalanges, is also important to be noticed, if
we desire to give a sure direction to the action of the bistoury.
The skin presents data so much the more important as its pathologic state
does not ordinarily deprive us of them. Amongst the number of folds and
wrinkles with which it is furnished on the dorsal side of the articulation, there
are three which should be particularly noted. The one which is perfectly
transversal corresponds always with the inter-articular line; the second, con-
vex towards the hand, lies over the point of union of the head of the posterior
phalanx with its body; the third, convex towards the end of the finger, guides
to the corresponding point of the anterior phalanx. The palmar side of the
distral phalangeal articulation is immediately beneath, or at the most at one
line in front of the only crease which the skin presents in this place. It is
the same with the middle articulation, in relation to the deepest line of the
teguments by which it is surrounded.
The metacarpo- phalangeal articulation, which is surrounded in the same
manner as the preceding by two lateral ligaments, and the flexor and extensor
tendons, has besides, before or on its sides the terminations of the lumbri-
cales and interosseous mucles, and the trunk of the collateral arteries, which
OPERATIVE SURGERY. 181
divides a little farther on. As this phalanx turns upon the head of the meta-
carpal bone, the latter is, during flexion, almost entirely concealed beneath
the former, which forms of itself the projection which is then remarked upon the
fist. These articulations are not all on the same line; the transverse mark in
the palm of the hand, which corresponds to the articulation of the fore and little
fingers, is found several lines behind that of the middle fingers. The best
means of discovering these joints, is to seek for them at about ten or twelve
lines from each interdigital commissure. From this disposition it arises, that the
small cushion of their anterior face may easily serve to form a flap capable of
completely covering the metacarpal bones after the removal of all the fingers.
§ 1. Partial Amputation.
Formerly the fingers were always amputated in the continuity of their pha-
langes, and by proceedings more worthy of a butcher than of a surgeon. Even
from the time of F. de Hilden, the operation was performed with cutting
nippers, a gouge, scissors, or some other instrument of a similar description,
accompanied by a blow with a mallet or small leaden hammer : more recently,
it was thought that a great step had been taken towards perfection, by the
substitution of a small saw in the place of the former instruments, which had,
according to Hilden, besides their coarseness, the inconvenience of breaking
the bones, and of giving rise generally to the most serious consequences.
Verdue, Petit, Garengeot, Sharp, and all the moderns, have opposed this
manner of operating, so that for along time the amputation of the fingers in
the continuity has been discarded. It is said that the operation is much
more difficult, and that the portion of phalanx which it preserves cannot be
of any use. On this point it appears to me that they have gone too far ; and
that in accordance with the ideas of Le Dran, Guthrie, and S. Cooper, it
would be much better when it can be done to saw the phalanx than to ex-
tirpate it entirely, for there is no part of any of the fingers which has not its
use and its importance.
1st. Manual. — A. In the Continuity. — Supposing that the disease is confined
to either of the two farther articulations, it is evident that it cannot be en-
tirely removed except by cutting the posterior phalange to a certain distance
from the affected joint, and that the remainder of the bone will not be without
its value to the patient. This slight operation may be performed by the cir-
cular or flap method.
Circular Method. — In the first case the operator incises the integuments
as near as possible to the diseased part. He then forces them back in order
to divide the tendons, and to make section of the bone with a little saw, at
about three or four lines higher than the point of beginning.
Flap Method. — In the second case the operator may content himself with a
single flap, which should be cut in front, or he may, as was already done by
Heliodorus, make two, each somewhat shorter than if it were alone, when
the state of the soft parts does not forbid. Immediate union should always
be attempted.
B. In the Contiguity. — Circular Method. — The operator here incises the skin
at about three lines in advance of the joint. The assistant draws it back to
permit him to divide higher up the extensor tendon, and to enter between the
phalanges from the dorsal side, after having divided the lateral ligaments.
In coming out through the joint to the palmar side, the bistoury, by a conti-
nuous movement, divides the flexor tendons. This method is very ancient, was
1^8 NEW ELEMENTS OF
pointed out by Garengeot, recommended by Sharp, Bertrandi, Leblanc,
Lassus, and others, and generally adopted in England ; is as good as any
other, and easily admits of immediate union.
Flap Method. — a. Process of Oarengeot. — Flaps of the same lengthy one
Dorsal, the other Palmar. — Garengeot recommends the method of Ravaton, or
rather that of Heliodorus, that is, to make two lateral incisions, united distrally
by a circular one, to dissect and raise the two flaps thus formed up to the
articulation, before passing through it, and then immediately to close the
wound.
b. Process of Le Dran. — Two Lateral Flaps. — Instead of making flaps
before and behind, Le Dran makes them lateral, and gives them a semilunar
form. This process has been described anew by M. Maingault, and justly
condemned by Blandin.
c. First Process of M. Lisfranc. — Single Palmar Flap. — An incision is
made through the skin at about one line in advance of the transverse crease,
so as to enter the joint at the first stroke. The operator immediately divides
the lateral ligaments, by inclining the bistoury a little first to one side and
then to the other ; the articulation being divided, there remains nothing more
than to cut a palmar fla^ long enough to close the wound completely. In this
way the operation is finished in the twinkling of an eye, and the cicatrix,
carried towards the dorsal surface of the finger, is more advantageously situ-
ated than if on the front, an advantage whicn may be disputed, and is cer-
tainly more than counterbalanced by the risk of seeing the phalanx denuded
behind. The disease besides is far from always permitting the operator to
give the flap a sufficient length.
d. Second Process of M. Lisfranc. — The diseased finger is held in supination,
the bistoury is passed flatwise between the soft parts and the front of the
phalanx, and forms on being brought out a similar flap to that in the preced-
ing method. The operator then raises up the instrument, and passes it through
the joint from front to rear, without leaving any posterior flap.
e. Another Process. — Single Dorsal Flap. — When the disease prevents the
formation of the flap in front, the first process of M. Lisfranc maybe reversed,
making the first incision at the distance of a line in advance of the palmar
crease, and forming a flap at the expense of the dorsal surface of the finger
But it is necessity, and not preference, that ever sends us to this operation,
/. Ordinary Process^ — Two Flaps. — M. Richerand, Gouraud, and others,
advise the formation of two semilunar flaps, one dorsal and the other pal-
mar, each three or four lines long. Modified in a way which I shall now
^describe, this process appears to me to be of more general application than
any other, and to be equally sure besides being more prompt in execution.
g. Two Flaps. — Palmar Flap longer than the other. — The operator seizes
the diseased finger, flexes it slightly and draws it towards himself, whilst an
assistant holds the root, bends the other fingers, or separates them from the
first, and fixes the whole hand in pronation. With a narrow bistoury, held
in the first position, the operator then cuts a small semilunar flap con-
vex towards the nail, following throughout the passage ot the anterior crease
in the skin. The divided teguments are withdrawn by the assistant; the bis-
toury which is carried up with them opens the articulation by cutting across
the extensor tendon, divides the lateral ligaments on the right and left, passes
between the articular surfaces, avoiding as much as possible the projections
which they present. Then, immediately upon arriving at the anterior liga-
ment, the edge of the instrument is turned forwards, so as to glide upon the
palmar surface of the disarticulated phalanx, and to form a flap of from four
OPERATIVE 8UROE11Y. 18$
to six or eigHt lines in length. The anterior flap is that upon which most
reliance should be placed, although the other is bj no means useless. In order
that it should not be cut too short, nor left too long, I think that before finish-
ing the division, it is prudent to imitate the practice of M. Delpech, in taking,
so to speak, an exact measure by applying it against the surface which it is
destined to cover.
2d. Dressing and After-treatment. — The operation being finished by one
method or another, it is hardly ever necessary to tie or twist the arteries.
The blood ceases to flow of its own accord, or with the assistance of a slight
compression. But if the arteries should be tied, each thread should then be
ranged in the corresponding angle of the wound: the two flaps being care-
fully brought together, are held in contact by one or two small diachylon
straps, which embrace the stump loopwise and extend to the wrist upon the
dorsal and palmar surfaces. A small rag pierced with holes and spread with
cerate, some dry lint, a fine compress, and a narrow bandage to confine the
whole, complete the dressing. A light diet for the space of two or three
days, and afterwards aliment somewhat less copious and succulent than
usual, is all that should be directed in regard to regimen. Provided the
hand is carried in a sling, confinement to bed is not necessary, unless in case
of accidents ; the best means of preventing these, and of even arresting them
when they begin to manifest themselves, is to establish an exact and regular
compression from the fore-arm to the wound embracing the hand, properly
padded on both surfaces.
f 2. Amputation of the Whole Fingtr,
Some surgeons, and Lassus among the rest, have laid down the precept^
that when the middle phalanx is diseased the first should be removed at
the same time; because, say they, this being preserved alone remains
immovable, and becomes a source rather of embarrassment, than of utility.
To remedy this inconvenience, which he explains by saying, that after the
removal o^ the second phalanx the flexor tendons lose their points of attach-
ment, and the power of acting upon the first phalanx, M. Lisfranc makes,
in the first place, one or two longitudinal incisions in front of the metacarpal
phalanx, through the whole thickness of the soft parts, so as to determine the
inflammation of the tendons and their adherence to the surrounding tissues;
this, however, makes two operations of one ; and as I have already remarked
elsewhere, and M. Scoutetten since, the object proposed by M. Lisfranc is
effected without operation by the fibrous cord which attaches one of the flexor
tendons to the first phalanx of the fingers. But even if this anatomical dis-
position did not exist, the immobility described by Lassus need not be appre-
hended. After the cure, the extensor and the flexor tendons are always
found fixed about the cicatrix, if not upon the bone itself, at least in such a
manner that nothing hinders them from extending or bending the stump.
And, in fact, observation proves that these fears are merely theoretical. It
is not therefore right to amputate the whole finger, unless the disease has
extended so far as absolutely to demand it, and will not permit us to ampu-
tate in the continuity, and saw the phalanx at a healthy point. Observing
that after the operation the two collateral fingers find themselves kept apart
in an unsightly manner by the head of the intermediate metacarpal bone,
M. Dupuytren, with Messrs. Sanson and Begin, prefers the amputation of
the latter bone in its continuity, to the simple disarticulation of the finger.
But the patient is exposed to greater risk by this method than by the other; and
]^34 NEW ELEMENTS OF
the head of the metacarpal bone after the disarticulation becomes flat, and
permits the two adjoining fingers to come nearer to each other, so that it is
wrong to pass the metacarpo-phalangeal articulation without absolute necessity.
This amputation is only practised according to the oval and flap methods;
the circular, vaguely indicated and followed by some practitioners, presents
nothing but inconvenience, and should be rejected.
A. Manual Flap Method. — 1st. Process of Sharp. — After having made a
circular incision upon the root of the finger in advance of the commissure,
Sharp makes another on each side in order to form a dorsal and a palmar flap
before reaching the articulation. This method is essentially bad, and is never
followed.
2d. Process of Garengeot. — The root of the diseased finger being first iso-
lated down to the articulation by means of two lateral and parallel incisions,
is then uncovered behind by a transverse or semilunar incision. There is
then nothing more to do than to divide the extensor tendon and the sides of
the capsule, to pass through the joint, and finisii by cutting the flexor tendons
and the skin which covers them. This is the method described by Bertrandi
and others. That which has been substituted lor it by many of the moderns,
only differs in that, instead of being united by a transverse incision, the
lateral incisions meet each other on the dorsal and palmar surfaces of the
articulation.
3d. Process of J, L. Petit. — The base of the finger, circumscribed by two
semicircular incisions, which pass over commissures and converge obliquely
so as to meet behind and before, is at once exposed laterally as far as the
articulation, which the operator opens and passes through either from one side
to the other, or from front to rear.
4th. By Puncture. — Instead of cutting from the skin towards the bones, as
just directed, Rossi plunges the bistoury through from the dorsal to the palmar
surface, and cuts successively the two flaps from within outwards, that is,
from their basis towards their free extremity. But this is a method which
has no advantage over the others, and leaves a more irregular incision than
that of Petit, of which it is nothing more than a repetition reversed,
5th. Process of Le Dran, improved by the Moderns, and especialli/ by M.Lis-
franc. — One or more assistants hold the hand turned in pronation and the
healthy fingers, which they remove from the median line, at the same time
keeping them extended. The operator seizes the diseased member with the
left hand, moves it about a little in order to ascertain more exactly the situ-
ation of the joint, which the anatomical data given above enable him to
discover. With the right hand he passes the heel of the bistoury, held in the
first position, on the back of the articulation, or begins about four or five lines
beyond ; carries the incision of the skin to the middle of the commissure of
one side, and by lowering the wrist prolongs the incision by a continuous
movement to the line which crosses transversely the palm of the hand in front
of the joint. The edge of the bistoury is immediately returned upon the con-
vexity of the semilunar incision, to divide the soft parts down to the articu-
lation, which is opened from one side by the blade of the instrument turned
across, as soon as it arrives behind the head of the phalanx. At this point of
the operation the assistant moderately draws the skin towards the wrist, and
to the right or left. The surgeon turns the finger as if to luxate it; cuts the
extensor and flexor tendons ; causes the teguments to be drawn in the oppo-
site direction, so as to keep them out of the way of the bistoury ; and closes
by forming a second flap, similar to the first, cutting from within outwards,
and from the metacarpus to the interdigital commissure of the opposite pide.
OPERATIVE SURGERY. 185
Remarks. — In order to allow the flaps greater length, Garengeot and others
advise to begin the first and terminate the second a few lines in advance of
the commissures. M. Lisfranc is of opinion that the upper part should be cut
square, and not in a point, as is generally done. It has appeared to me that, by
carefully bringing towards each other the bases of the fingers, the operator may
very easily bring the two sides of the incision in contact, without having
recourse to those precautions which by the way are no otherwise bad than as
making the skin liable to be curled back upon itself, and as rendering the
operation a little less easy.
After making the first incision, to avoid the risk of going beyond the head
of the metacarpal bone it is well to feel with the index finger for the internal
tubercle of the phalanx to be removed. This is an easy thing, since it is the
first projection which is found in tracing the face of the bone into the palm.
It is well to prolong the first incision of the integuments nearly half an inch
beyond the articulation. This makes it easier to cut the surrounding fibrous
parts without touching the other lip of the incision, and enables us to cut the
second flap more regularly.
When the operator has taken the precaution to graze the sides of the pha
lanx and to avoid passing the head of tlie metacarpal bone, the trunk of the
collaterals is generally found preserved ; he has then but two arteries requiring
his attention, and which he may tie or twist, if the blood does not of itself
cease to flow.
This is the quickest process, and presents no other inconvenience than
that of not always giving to the last flap the same regularity, nor exactly the
same form as the first. In this respect the process of Petit is to be preferred.
Oval Method. — The hand of the patient, the assistants, and tiie operator,
being disposed as in the preceding case, the surgeon lays hold of the diseased
finger with the left hand, gently flexes it drawing it at the same time a little
away from the others, begins the incision on the dorsal surface farther back
than the articulation with the heel of the bistoury, which he draws gently
forwards to the edge of the commissure and with which he turns the palmar
front of this finger, cutting exactly on the semicircular line by which it is
separated from the hand, properly so called. Having arrived at the opposite
border, he applies the bistoury again to the anterior or phalangeal extremity
of the wound, and then draws it back obliquely towards the metacarpus, so as
to unite the two extremities of the incision. Without quitting his hold upon
the part to be removed, the operator causes the lips of tlie division to be sepa-
rated as much as possible, cuts the extensor tendon, then the lateral ligaments
and the posterior half of the articular capsula, increases the flexion of the
finger, drawing it as if to disjoint it, passes the bistoury to its palmar face by
traversing the articulation, and finishes by dividing the flexor tendons and
the soft parts which unite the front of the phalanx to the cellular cushion of
the palm.
Instead of turning the palmar side of the finger after reaching the com-
missure, it is more convenient to make the second incision in the same manner
as the first ; the disarticulation is then performed, and the rest of the operation,
according to the directions just given. An incision in V is thus made, and
the wound does not present an oval form until the end of the operation.
According to the oval method the trunk of the collaterals is seldom divided,
and is consequently always easy to tie, if this is thought necessary. If too
great an extent has not been allowed to the point of skin which is removed
with the finger, the two lips of the incision meet without difficulty, and imme-
diate reunion is rendered more certain and more sure by this than by any
24
1^0 KfeW ELEMENTS or
Other method. This, therefore, is the method which merits general adoption,
inasmuch as it does not require that the skin should be healthy to the same
extent as required bj the others. iThe division which results, leaving the pal-
mar cushion untouched, presents in reality a surface of one half the extent
of that left by the flap method, and its regularity renders coaptation always
easy. But to execute it well, it is necessary to possess positive anatomical
knowledge, to be very skillful, and to have practised it upon the dead subject.
§ 3. imputation of the Fingers Collectively,
Although amputation of all the fingers together had been performed before,
M. Lisfranc was the first to give regularity to this operation, to show its ad-
vantages, and to describe its mechanism. The particular cases which require
it may be easily conceived, without entering into further details ; cases of this
kind do occur, but it is very rarely.
Manual. — The hand and fore-arm being held, as for the amputation of a
single finger, the operator lays hold of those which he wishes to remove, by
placing the thumb across their dorsal, and the left hand upon the palmar
face, flexes them moderately, and requires the assistant to stretch the skin
by drawing it backwards. Then with a straight bistoury he makes a trans-
verse incision, slightly convex forwards at about three or four lines below the
extremity of the metacarpal bones, being careful to begin towards the index
finger, if he operate upon the left hand, and towards the auricular in ope-
rating upon the right. This first incision lays bare the extensor tendons and
the posterior face of the articulations. As soon as the integuments have been
suitably drawn back, the surgeon opens the different articulations, passes
through them, and divides their anterior ligaments. There remains nothing
more for him to do than to pass in front of the heads of all the disarticulated
phalanges a narrow knife, with which he cuts forwards a large semi-elliptical
flap, naturally limited by the groove which unites the palmar face of the
fingers with that of the hand. This same knife might also serve for the dorsal
incision ; but as it has to pass alternately upon the projections and the hollows,
the bistoury is somewhat more convenient. To avoid the subsequent projec-
tion of the flexor tendons, it is necessary to cut them upon a level with the
articulation before finishing the flap. The arteries opened in this operation
are eight in number. As the operator bends them at an angle in raising the flap
in order to close the wound, the use of the ligature is generally dispensed
with. The palmar flap most comm.only being the only one, and always of
the greatest length, does not require to be united to the dorsal flap by
suture. Adhesive straps suflice to maintain it, firmly applied against the
heads of the metacarpal bones ; a piece of linen pierced with holes and covered
with cerate is next applied, and is in its turn covered with a thin layer of lint,
over which is laid a fine compress and several narrow strips, which embrace
the stump either directly or obliquely in the same direction as the plastic
straps. After having suitably cushioned the palm of the hand, nothing more is
to be done but to confine all these pieces with a bandage, which should extend
itself bv turns more or less close and moderately tight to just above the wrist,
and pass once or twice between the root of the thumb, the rest of the hand,
and the free extremity of the stump.
OPERATIVE SURGERY. 187
After the removal of a single finger, the same bandage, or nearly the same,
is applicable. But it should make some difference whether flaps have been
preserved or not. In the first case a narrow strip of diachylon fixes the pieces
of skin over the end of the bone ; whilst in the second it is sufficient to place
one across, and to bring as near together as possible the roots of the two ad-
jacent fingers, by pressing upon the edges of the hand with the bandage. The
same is done when the oval method has been followed.
§ 4. Accidents,
However easy and trifling it may appear, the amputation of the fingers fre-
quently gives rise to very serious accidents. A man and a woman died after this
operation in 1825 and 1826, at the Hopltal de Perfectionnement, and one of
the patients upon whom I operated in 1831, at La Pitie, met the same fate.
I could very easily adduce many such examples. It is sufficient to say that
this operation should not be decided on without caution, nor for diseases
which do not absolutely require it. The dangers arise from the inflammation
which, through the intervention of the tendinous grooves, the sheaths, the sy-
novial membranes, and of the very loose lamellar tissue of the dorsal and pal-
mar faces, either of the phalanges of the hand, spreads with a frightful ease and
rapidity in the direction of the wrist, involving at once the soft parts, the arti-
culations, and the surface of the bones, which soon become the seat of a
suppuration which nothing can arrest. To lay open the fibrous theca of each
finger which has been amputated, as advised by Garengeot Bertrandi, and
latterly by Barthelemy, would not in any way prevent the development of
these dangerous inflammations, which are entirely independent of every thing
like strangulation. When cataplasms or an abundant application of leeches
fail to at once arrest its progress, nothing but numerous and deep incisions can
give real relief. The remedy is indeed painful, but the question is of life or
death; and no man who has had an opportunity of appreciating its sometimes
miraculous effects, will hesitate an instant.
Art. 2. — Metacarpus,
Like the fingers, the bones of the metacarpus can be amputated in conti
nuity or at the articulations, separately or together. They can also be partly
cut out or wholly extracted, leaving the fingers which they support.
§ 1. /n the Continuity.
If the first and last metacarpal bones are rarely amputated in the continuity,
it is nx)t so with those which support the index, middle, or fourth finger.
These bones are swollen at both ends ; concave towards the palm ; convex
and broader upon their dorsal face, which is only covered by the flat tendons
of the extensor muscles of the fingers, a thin cellular lamina, veins, and the skin,
and separated by smaller spaces in the direction of the wrist than elsewhere.
They form all together a species of grate, bulging out behind, the concavity
of which is occupied by the interosseous muscles, the tendons of the flexors,
the lumbricales, the two arterial arches of the hand and the branches which
188 NEW ELEMENTS OF
arise from them, the radiation of the median nerve, the muscles of the thenar
and hjpothenar eminences, the palmar aponeurosis, and the common inte-
guments. Thej enjoj but little motion at their proximal articulations, but
can be brought together so as to incline one before another at their digital ex-
tremity, whence it follows that when one of them has been obliquely sawn
in the middle, it is easy to cause in a great degree the disappearance of the
hollow which results, and that the deformity which follows such an amputation
is less marked than after the simple removal of a finger. The phalangeal
tuber continuing in the state of epiphysis until the age of from six to ten years,
may, according to M. Lisfranc, be removed with the bistoury, from the hands
of children, if the disease requires it, in amputating with one or all of the
fingers. At a more advanced age, the saw is indispensably necessary. The
scissors, the gouge, and the mallet, have been used for the removal of the bones
of the metacarpus, the same as in the amputation of the fingers, although less
frequently.
1st. Amputation in mass. — Louis performed the operation by means of the
saw, so as to leave only the posterior moiety, for a young girl, who was very
glad to keep the rest of the hand. Perhaps it would be better to cut them
across in this w^ay than to disarticulate them, if the extremity alone were
affected. The operation could not be very difficult. A semilunar incision
convex towards the fingers would expose the dorsal face of the metacarpus;
a narrow knife pushed through flatwise from one edge of the hand to the other
between the bones and the soft parts, could form a palmar flap of about twelve
or eighteen lines in length ; a bistoury might then disencumber each meta-
carpal bone of the tissues by which it is surrounded, so as to permit it to be
sawn through with greater facility and neatness.
2d. Amputation of a Single Bone. — The parts being disposed and held in
the same manner as for the amputation of a finger, the operator passes
through the whole thickness of the hand from the back to the palm, several
lines beyond the seat of the disease. In doing this he first causes the point
of the bistoury, held in the third position, to fall perpendicularly upon the
bone ; then carries it a little to one side, cutting the skin in its passage ; then
turns it in a proper position to graze the side of the bone, brings it nearer to
the median line as its point emerges upon the palm, and concludes the opera-
tion by cutting towards himself with the full edge to the middle of the corre-
sponding interdigital commissure. After this first incision he makes another
exactly similar on the opposite side, but in such a manner that the two should
only form one in the rear ; that is to say, that the thumb and fore-finger should
draw the tissues to the left, while the bistoury, reapplied at the beginning of
the first incision, is inclined so as to fall upon the first incision in the palm.
The operator then cuts the soft parts which may remain attached to the bone,
by exploring its whole circumference with the point of the instrument. A
small splint made of wood, lead, or pasteboard, or a thick compress, is then
thrust into the wound, so that the fine saw which is to divide the metacarpal
bone with a long slope from front to rear, may not injure the flesh. The
slope is to be replaced on the cubital side of the last two fingers and <!ii the
radialside of the first two,because of the particular species of motion which the
carpo-metar carpal articulation admits.
When the bistoury is not carried too far outwards, the collateral arterie*
OPERATIVE SURGERY. 189
are not generally opened except at the base of the finger. In the conti-ary
case the operator runs a risk of dividing the common trunk to the right
(ind left, which does not generally prevent him from dispensing with ligature
or torsion.
At the time of the dressing it is requisite to keep the lips of the incision
somewhat near each other, by means of several circles of diachylon placed
across, and of three or four turns of a bandage. In attempting to obtain ?
perfect coaptation the operator strains the posterior articulation, which may
give rise to serious accidents; such as inflammation of all the synovial
surfaces of the carpus, of the surrounding tendinous sheatlis, &c. This
operation, which is not sensibly more difficult than the disarticulation of a
finger, produces a sanguineous surface, a wound three or four times larger ;
requires the division of soft parts, which are more delicate and more
numerous, so that in this particular, at least, it is really much more serious,
and recourse should not be had to it until after having fully ascertained the
insufficiency of the other.
§ 2. In the Contiguity,
All the bones of the metacarpus may be disarticulated separately, and
amputated with the finger with which they correspond. They may also be
amputated all together or only the four last, at a single operation. But this
kind of amputation is almost exclusively performed upon the first and the
fifth, since it is much more easy to amputate the others in continuity.
A. Metacarpal of the Thumb. — imputation. — The mobility of this bone
and its shortness are reasons why it is scarcely ever sawn, and why disarticu-
lation is preferred when this part is diseased. In all cases if its anterior
extremity is alone affected, I do not see from what reason one could refuse
to divide it immediately behind. No particular danger could attend this
operation, which would not be difficult, and might be performed by the
circular or flap method.
Anatomical Remarks. — The metacarpal bone of the thumb lying just
beneath the skin, behind and on the outside, and concealed by the thickness
of the thenar eminence in front, holds, at its carpal extremity, relations well
worthy of notice. Its articulation with the trapezium lies in an oblique line
drawn to the root of the little finger, and holds in some sort a middle place
between the ginglymus and the enarthrosis. It is surrounded by a very loose
capsule, may be opened in all points of its circumference, but principally by
the two posterior or dorsal thirds. The tendons of the long abductor and of
the short extensor of the thumb, garnish and support the part which is nearest
the skin ; the radial artery winds round the cubital side in its progress to the
palm of the hand, to form the deep palmar arch. As for the tendons of the
long flexor and extensor, their position in front and behind is too well known
to require particular attention here. The situation of the joint is determined
by sliding the fore-finger towards the wrist, along its dorsal face or one of its
sides. It is immediately behind the first tuberosity which is encountered.
Manual. — The operator performs the operation of disarticulation of the
first metacarpal in many different ways, and with ease by all, if he has any
skill or address.
190 NEW ELEMENTS OF
1st Tlie Ancient Method, — If the surgeon is not ambidexter, the hand of
the patient should be held in pronation on the left side, and in supination on
the right, otherwise, the operator places the hand in pronation for either side.
Whilst the assistant clasps the wrist with one hand, and holds the roots of the
last four fingers with the other, the operator lays hold of the thumb, and holds
it in a state of abduction ; applies the edge of the bistoury held in the first
position with tlie point upwards against tlie middle of the commissure ; divides
the whole thickness of the soft parts, grazing the cubital border of the bone
as far as the carpus ; extends the incision of the teguments from four to six
lines upon its dorsal and palmar surfaces, towards 'die wrist; opens the joint
with the bistoury turned outwards ; divides all the fibrous parts with the point
rather than with the edge of the instrument, so as to avoid the skin; turns the
thumb at the same time to the radial side, luxes it,, and after having passed
through the articulation, cuts the flap towards himself, grazing the external
surface of the bone, and extending it to some lines in advance of the metacarpo-
phalangeal articulation. In order to preserve for this flap particularly, at its
base, a sufficient breadth and thickness, it is advantageous in passing through
the interosseous space, to incline the handle of the bistoury a little to the
hypothenar eminence, and to direct the edge towards the os-pisiforme, or the
cubital border of the carpal extremity of the radius. By extending the inci-
sion of the skin to some lines beyond the carpo-metacarpal articulation, you
secure the means of disjointing the bones, without bruising or cutting the edges
of the flap which is to cover the wound.
If the radial artery itself has been injured, the use of the ligature is requisite ;
otherwise, an exact coaptation of the surfaces will render this useless. After
having applied the adhesive straps, it is well still to lay a quantity of lint, or
a graduated compress upon tlie external face of the flap, the base of which
requires to be strongly pressed against the second metacarpal bone.
2d. Jlnother Method. — An assistant is charged with the thumb; the surgeon
seizes with the first three fing-ers of the left hand and draws outwards as
much as possible the soft parts, plunges the bistoury by puncture from the
dorsal to the palmar face of the thenar eminence, gliding along the radial side
of the articulation, cuts a flap as before directed, turns it back, and causes it
to be held by the assistant. He then takes the thumb himself, separates the
lips of the incision, passes through the articulation from the outer to the inner
side, luxes the bone, and terminates the operation by bringing the bistoury to
the same point where the preceding operation should commence. As the
definitive result is exactly the same in both cases, and as by the latter metliod
it is always inconvenient to effect the disarticulation, the former should be
preferred. Instead of forming a flap from within outwards, by puncture, one
might cut it in the opposite direction, that is, begin by tlie division of the
teguments, and then dissect the flap backwards from its free extremity to its
base. This would allow it with more certainty all possible regularity, and
just the dimensions required.
3d. New Process. — I have often amputated the thumb in the following
manner : — A dorsal incision carried from the styloid apophysis of the radius
to the commissure of the thumb and fore-finger, dividing the integuments,
the tendon of the long extensor with a part of the first interosseus muscle
at once exposes the articulation. Whilst the assistant separates the lips of
W
OPERATIVE SURGERY. 191
the incision, the surgeon divides the capsule, luxes the bone which he then
removes, preserving as much of the thenar eminence as is necessary for the
immediate closing of the wound. The palm of the hand being thus respected,
permits a flap to be made of the form and extent required, without having
any special obstacles to surmount.
4th. The Oval Method. — Lassus, Beclard, and Richerand, have many years
ago described this method of amputation. The operation is begun in the
manner just described. The operator turns the anterior face of the root of
the thumb, comes up upon its dorsal face, and unites this second part of the in-
cision to the extremity of the first. In the second step he carries the point of
the bistoury upon the joint through which he passes from the dorsal to the
palmar side, after which nothing more remains than to detach the bone from the
flesh which adheres to it, by sliding the instrument between them from the
wrist forwards. A very long oval incision is thus obtained, the lips of which
may be united with the greatest facility, leaving nothing between them but a
simple linea trace. It is the most simple and the best of all known methods,
but is somewhat more difficult than the preceding, which gives nearly the same
results.
Extraction. — We may conceive that this bone may suffer necrosis, or become
careous, without affecting the thumb or the carpus, and it would be important
to be able to remove it and at the same time to preserve all the other parts.
M. Troccon advocates, in a memoir presented to the institute in 1816, the
possibility of this extraction ; but M. Roux appears to have been the first to
use this method successfully upon the living subject. The thumb of his
patient which at first was rendered entirely useless, recovered by degrees its
natural functions, so as to be able to execute quite extensive movements. I
know a person, in whose case the first phalanx was affected with necrosis, and
extracted by fragments, without impairing to any great degree the motion of the
thumb. I was myself ignorant, in 1825, of the fact that this operation had
been mentioned by M. Troccon ; and as M. Roux has nowhere described his
operation, I thought proper to enter into some details as to the best method of
procedure, in my work on surgical anatomy. This operation having been per-
formed successfully, in 1827, by M. Blandin, may at the present period be
ranked with the regular operations.
An incision is first made parallel to the radial border of the bone to be
removed, and is extended at least half an inch behind and before both its
articulations. The operator then carefully detaches the teguments and the
tendon of the long extensor from its dorsal face ; the same operation is per-
formed upon the opponens muscle and the long flexor which cover its palmar
face. While an assistant forcibly separates the two lips of the wound, the sur-
geon introduces the point of the bistoury upon the external side of the carpal
articulation ; divides the tendon of the long abductor ; does the same with
the short extensor, always cautiously avoiding the long extensor of the thumb ;
destroys all the ligaments and fibrous parts which connect the metacarpal
bone to the trapezium ; endeavors to lux this bone outwards, either by a simple
swaying movement or by drawing it in that direction with the forceps; takes
it then in his fingers, passes the bistoury along its cubital side to separate it
from the flesh, and disarticulates it by dividing successively the internal and
external lateral ligaments, and then the anterior fibrous strata which unite it
19B NEW ELEMENTS OF
to the thumb, which is left supported bj its long extensor, long flexus, short
abductor, short flexus and adductor, preserving in short the whole thickness
of the thenar eminence. No artery of any size need be opened. The usual
dressings are applied, with the addition of lint or compresses so placed as with
the aid of the bandage to keep the thumb in its natural position.
B. Fifth Metacarpal Bone — Amputation, — The bone which supports the
little finger is removed by the same methods as that of the thumb. Its arti-
culation with the os-unciform lies obliquely, in the direction of a line which
would fall in front of the articulation of the trapezium with the first metacar-
pal bone, and it is connected with that which supports the fourth finger by a
facet nearly plane, and two or three ligamentous bands. Its situation is
recognized from without, by following the dorsal face of the bone with the
end of the fore-finger. Before coming opposite the os-pisiforme, the operator
meets a slight protuberance, and immediately after a slight depression, which
falls exactly upon the line of the articulation.
1st. When the Process of the Ancients is followed, there is no danger (as in
the case of operation on the thumb) of seeing the bistoury entangled between
bones in the carpus. It may therefore be carried boldly as far as the unci-
form bone, along the radial side of the bone to be removed, with the edge
directed toward the median line of the wrist, in such a manner as to preserve
almost entire the hypothenar eminence. After the inter-metacarpal ligament
is divided, the point of the bistoury, which is then inclined towards the ulna,
easily enters the articulation. As the other fibrous tissues are divided, the
finger should be bent to the ulnar side, so that the instrument may clear
the articulation, and isolate the base of the flap. This is cut forwards,
extending beyond the metacarpo-phalangeal articulation, while the little
finger is returned nearly to its natural position.
2d. The Second Process, which is begun by forming a flap, by passing
through the flesh from one face to the other of the hypothenar eminence
before having separated the fifth metacarpal from the fourth, belongs, I be-
lieve, to M. Lisfranc. It must be admitted that it is here more advantageous
and easier of application than on the other border of the hand. The soft
parts are better adapted to the formation of a sufficient flap by this method ;
but the disarticulation is here, as there, more diflicult than by the preceding
method.
3d. The process which I sometimes adopt in amputating the metacarpal
bone of the thumb, does not always apply with the same advantage to that of
the little finger, where the oval method is evidently better. The incision
being commenced before the styloid apophysis of the ulna, is carried obliquely
along the edge of the hand as far as the root of the little finger, and passes round
the palmar face of that member from the ulnar to the radial side. This
incision stops at the commissure, but by a second application of the bistoury,
is prolonged upon the back of the hand, so as to meet at an acute angle with
the first part of the incision. It would be equally easy to begin so as to fall
upon the commissure of the last two fingers, and finish by an internal incision.
The disarticulation has nothing peculiar.
Extraction. — This bone, as well as the metacarpal of the thumb, may be
extracted and that quite easily ; but as the little finger is not of so much im-
portance as the thumb, it will perhaps always go with its metacarpal bone.
OPERATIVE SURGERY. 1$3
whenever that shall require to be removed. But if this bone is to be sepa-
rately removed, it may be done by a method precisely analagous to that recom-
mended for the extraction of the corresponding bone on the other side of the
hand, beginning with a dorsal incision from the head of the ulna to the middle
of the ulnar side of the little finger.
Central Metacarpal Bones. — jimputation. — Although not absolutely imprac-
ticable, the disarticulation of these three bones is, it must be confessed, much
more difficult than that of the first two, so that surgeons generally prefer to
amputate in continuity. Still, if it is thought best to have recourse to it, this
operation may be performed by means of the flap or oval method.
1st. Flap Method. — Metacarpal Bone of the Index. — The bistoury, carried
from the commissure to the carpus, soon arrives at the ligament which con-
nects this bone to the metacarpal of the medius. It is then raised so as to cut
the dorsal ligament, and lowered to divide the palmar ligament ; the finger is
inclined towards the thumb, the articulation opens, the point of the instrument
crosses it, and the operation is finished by forming a flap on the radial side,
which should extend farther forward than the metacarpo-phalangeal articu-
lation.
Metacarpal Bone of the Medius. — The bistoury is carried between the two
middle fingers. The operator before attempting the disarticulation, should
extend the incision in front and behind towards the wrist, to the distance of
about half an inch, turning it somewhat towards the median line; this joint
being in a position rather oblique from the ulna towards the radius, and from
before backwards, would occasion much more difficulty if the operation were
commenced on the other side. When the dorsal and palmar ligaments have
been divided ; when the bone which is to be removed has been separated from
that of the ring-finger, the surgeon acts upon the anterior extremity, as if to
disjoint it at the other ; he then endeavors, while the assistant draws the lips
of the incision towards the thumb, to disengage its carpal extremity, to which
the tendon of radialis brevior is attached. This being done, the full edge of
the bistoury is rapidly passed along the radial face of the bone, as far as the
commissure of the index and the medius.
For the Fourth Metacarpal Bone, the surgeon should carry the bistoury
through the same interspace ; prolong the incision toward the wrist in the
same manner, but with this difference, that he incline it toward the ulna, sepa-
rate the two contiguous osseous facets, divide the ligaments as in the preceding
case, and bear in mind that the articulation of this bone with the magnum and
the unciform, is oblique from the radial to the ulnar side, and from before
backwards, and that it is continuous with that of the fifth.
2d. Oval Method. — M. Langenbeck was the first to practise with success
the extirpation of one of these bones by the oval method. The operator
divides the integuments upon their dorsal faces, beginning half an inch beyond
the carpal articulation ; extends his incision to one of the digital commissures;
brings it back on the otlier side, by turning the palmar front of the root of
the finger, and then unites the two extremities of the incision, cutting towards
the wrist, or he may cut from the wrist, making an incision similar to the
first, on the other side of the bone which is to be removed. Whilst the
assistant separates as much as possible the lips of the wound, the surgeon
cuts successively and without violence with the point of the bistoury, the liga-'
25
194 NEW ELEMENTS OF
inent of the articulation, and with the other hand endeavors to disjoint the
bone. When at last this has been effected, the bistoury, held in a flat and
horizontal position, slides along the bone so as to divide from the carpus
towards the root of the finger all the soft parts which are still attached to
its palmar face.
Extraction. — M. Troccon has not only advised the separate extraction of
the metacarpal bone of the thumb ; he thinks that the same operation should
be attempted upon the others. I have frequently practised it upon the
dead subject, and I must say, that with an exact knowledge of the anatomy
of the articulations, it may be done without much difficulty. An incision
is carried from the carpal extremity of the fore-arm to the distance of
about half an inch in advance of the phalangeal articulation, carefully
avoiding the extensor tendon. In order to disarticulate the bone at its
proximal extremity, the operator acts as in the preceding cases ; after luxing
it, he seizes it with two fingers, or with the forceps, while with the point of
the bistoury he proceeds to divide the posterior part of the capsule, ih^ lateral
ligaments and the anterior ligament of the other articulations, carefully avoiding
in every instance the extensor and flexor tendons of the corresponding finger.
Instead of beginning at the proximal extremity, as advised by M. Troccon,
I think, with Mr. Blandin, who revived the idea in 1828, that it would be
better, first, to disarticulate the phalangeal extremity, and to close the ope-
ration by dividing the carpal ligaments ; but it is probable that notwithstanding
the success obtained by Mr. Walther, this operation will continue to be, for
a long time to come, a mere project with the greater part of the practitioners.
The division of the diseased bone, I think, may almost always be advan-
tageously substituted for it.
E. Disarticulation of several, or of all the Bones of the Metacarpus together.
When the whole hand is found to be attacked but in such manner as to leave the
carpo-metacarpal articulation untouched, is it necessaryto remove the wrist }
If all the dogmatical treatises on surgery are to be believed, there could be
no doubt upon this subject, or rather it is a question with which their authors
have not troubled themselves. In disarticulating only the metacarpal bones,
the operation preserves a greater length for the fore-arm, a movable portion
of the limb, and undeniable advantages in the application of an artificial hand.
M. Larrey affirms, that for a long period the military surgeons have had
recourse to this operation; M. Yvan also remarks, that several soldiers in
the Hospital of Invalids have submitted to it, and always with success. And
a number of other authors might be cited to prove the operation prac-
ticable, although they do not always consider it advisable. In every instance
where it is possible to preserve the thumb or any other finger, by means of it,
there is no question of the propriety of resorting to it. As a general rule,
the disarticulation of the carpus from the metacarpus should be preferred to
the amputation of the wrist. It cannot be denied that after the cure the car-
pus can be of very great advantage to the patient, even if he do not desire to
make use of an artificial hand. But this is an operation which requires prac-
tice and very precise anatomical knowledge; so that if the surgeon is not suffi-
ciently confident in himself to perform it securely, he ought not to undertake it.
1st. Anatomical Remarks, — The relations of the first and fifth metacarpal
bones with the trapezium and the unciform, have been already discussed.
OPERATIVE SURGERY. 195
The metacarpal bones of the index finger is loosely connected externally
with that of the thumb ; more firmly within with the third ; and presents behind
and externally a tuberosity which extends some lines towards the wrist and
gives attachment to the tendon of the radialis longior. Its proximal extremity
is articulated externally to tlie trapezium, and by its two internal thirds to
the trapezoides. The third metacarpal also presents a tuberosity, which tends
to slide behind the line between the os-magnum and the os-trapezoides, and
gives attachment to the tendon of the radialis brevior. Its proximal surface
being oblique from the radial to the ulnar side, rests upon nearly the whole
extent of the corresponding front of the os-magnum; while that of the fourth,
having a similar slope inwards and backwards, is connected with the radial
half of the anterior surface of the os-unciform, then to a similar surface pre-
sented by the os-magnum, and forwards and towards the ulnar side.
All tliese bones are held together by means of dorsal ligaments in the form
of longitudinal and transverse bands, by palmar ligaments much more irre-
gular, and by fibrous fasciculi, which fill the spaces between the points of their
proximal extremities in the palm. Their synovial cavity is continuous with
that of the carpus, and consequently extends between the two ranges of that
part, so that inflammation of the osseous surfaces after this amputation
must indeed be excessively dangerous. Looking at all these articulations on
their dorsal face, it is perceived that that of the first metacarpal bone being
oblique forwards and inwards, terminates one or two lines before that of the
second, the line of which turning at first almost directly backwards, soon
becomes nearly transverse ; before leaving the trapezium, and with a semi-
lunar sweep, concave forwards, arrives upon the trapezoides. It then turns
obliquely backwards before leaving this bone, and joining the third metacar-
pal. The articulation of this latter begins about half a line nearer the wrist
than the termination of that of the second, and proceeds obliquely inwards^
and forwards in a line which would fall upon the posterior quarter of the fifth
bone. It terminates two or three lines nearer the fingers than the commence-
ment of the articulation of the fourth. This follows at first such a direction,
that if continued it would be lost in the pisiforme bone, then takes a trans-
verse direction on arriving upon the unciform, and continues with scarce a
line of demarcation into that of the last metacarpal, which is also somewhat
oblique to the rear. The mode of ascertaining from without the situation of
the first and fifth of these articulations, has been already described.
2. Manual of the Operation. — A. Process adopted by the Author. — An assist-
ant supports the fore-arm, and compresses at the same time the ulnar and
radial arteries ; the hand of the patient being turned in pronation is clasped
by the operator, who seizes only the four fingers when he wishes to leave the
thumb. With a straight bistoury or a small knife he makes a semilunar inci-
sion convex forwards, about half an inch in advance of the articular line,
which has just been described. The assistant then draws the skin in the
direction of the fore-arm. With a second stroke of the bistoury, the surgeon
then divides all the extensor tendons, and immediately proceeds to the disar-
ticulation. Beginning on the radial side, if he is operating on the left hand,
and on the ulnar, if he is operating on the right, he draws the point of the
bistoury along all the windings of the dorsal aspect of the articular line, foi
there is no need of penetrating it to divide the ligaments.
196 NEW ELEMENTS OF
During this manoeuwe, the operator acts with some force upon the anterior
extremity of the hand, as if to disjoint it. All the articulations being once
opened, the point of the bistoury is reapplied, in order to divide any fibres
which may still connect them. When they are completely separated, the
knife glides by degrees towards the palm of the hand, assumes a horizontal
position, and cuts a flap in the shape of a half-moon, of the length of an inch
or an inch and a half, grazing the palmar face of the metacarpian bones,
which are to be removed. The terminating branches of the radial and ulnar
arteries have necessarily been divided. Those of the former are found upon
the dorsal aspect of the wrist, and near its radial border; the second should
be sought for on tlie internal side of the pisiforme bone. Immediate union,
which is of the greatest consequence, requires the same precautions as are
used in cases of simultaneous amputation of all the fingers at once.
b. Proceeding of M. Maingault. — This author would have the surgeon to
begin by forming the palmar flap with a small knife, inserted between the
bones and the soft parts of the hand. A semicircular incision is then made
upon the dorsal face of the metacarpus, at about one inch from the articulation,
and while an assistant draws back the flaps, the operator, leaving his posterior
incision, exposes in front the articular line, and passes through the joints from
the palm to the back of the hand.
The experiments I have made with this process have satisfied me that it is
not very difficult. But it appeared to me, whether from want of skill in me,
or from real imperfection in the process, that the other was to be preferred.
If the first two or the last two metacarpals should require to be removed by
themselves, the operation must be subjected to some modifications. It would
be necessary in the first case, for example, to begin by making a transverse
incision a little in front of the articulations, then to make another parallel to
the axis of the metacarpal bones upon the back of that which supports the
little finger, so as to make there a dorsal flap to cover the whole ulnar side ©f
the wound after the operation. That being done, and the disarticulation being
effected, the operation is finished by forming a flap one or two inches long,
which must be detached down to its base from the palm of the hand, so that
it may be applied upon the transverse branch of the wound. The operation is
nearly the same for removing the thumb and the index, or the index and the
medius.
In case the operator wishes to remove at the same time some of the bones
of the carpus, no rule can be laid down beforehand. The surgeon must
rely upon his own knowledge and resources for these trifling operations.
^rt, 3.— 7%c Wrist,
At the present day, according to Percy, it is only at Tunis and such like
places that they use, in amputating the wrist, like the ancients, a hatchet
moved by a weight falling from above between two grooved uprights, or of a
strong chisel, whicli the operator strikes with a leaden mallet. Let us add
that there is no person who now believes in the propriety of amputating the
fore -arm, when to remove the disease entirely it is sufficient to disarticulate
the hand. Amongst the moderns, there are many surgeons to be found who
consider this latter operation dangerous; the facts reported by Slotanus,
OPERATIVE SURGERY. 197
Hilden, Paignon, Leblanc, Audouillet, Hoin, Sabatier, Brasdor, Lassus, M
Gouraud, and others, who affirm that it almost always succeeds, have not
entirely dissipated the fears which it had previously inspired.
Anatomical Remarks. — The radio-carpal articulation is surrounded by nu-
merous tendons, sheaths, and synovial membranes, and presents also this
circumstance worthy of remark, that it terminates at both extremities of its
greater diameter in the apophyses of the radius and of the ulna, which give it
the form of a half-moon, transversely concave, slightly concave also backwards,
lodging a species of head formed by the scaphoides, the semilunare, and the
trapezium ; and held in place by internal and external posterior and anterior
ligaments. As the first range of the carpus diminishes towards its extremities,
particularly towards the cubital side, a line drawn transversely from the styloid
process would easily fall between that range and the second ; the pisiforme,
the point of the scaphoides, the crest of the trapezium, and that of the un-
ciform bone, jut out beyond the level of the palmar front of the radius and
of the cubitus, far enough to command attention at the time of operation.
The skin of the anterior face of the wrist presents, almost constantly, three
wrinkles, which may be of great use in directing the course of the instruments.
The first, which is the most constant, is found immediately above the thenar and
hypothenar eminences, and corresponds with the line between the two ranges
of the carpal bones : the second, which is perceived from four to six lines in
the rear, falls upon the radio-carpal articulation, and the third, still higher
towards the elbow, commonly corresponds with the junction of the epiphyses
with the shafts of the radius and ulna. When these wrinkles are imperfectly
developed, bending the hand is generally sufficient to display them more
Manual. — The amputation of the wrist is only practised by the circular or
flap method : the disposition of the articular surfaces, and the thinness of the
soft parts, render the oval method inapplicable.
A. Circular Method. — The surgeons of the last century contented them-
selves with saying, that the amputation of the wrist should be effected in the
same manner as that of the fore-arm or of the leg, without entering inf » any
further details on the subject, so that it may be concluded that they used the
circular method, which has been clearly described by J. L. Petit, the only one
indicated by Lassus, and Sabatier, and that which still presents the greatest
advantages and the greatest facility. The assistant who has charge of the
fore-arm, draws the teguments forcibly backwards ; the surgeon seizes the hand
of the patient, holds it in a flexed posture, while he cuts upon the dorsal
face ; inclining it towards the radius, while he cuts on the inside ; towards
the ulnar, when on the outside ; and in extension, the moment the instrument
is passed below. In this manner he makes an incision regularly circular, a
full finger's breadth in front of the apophyses of the fore-arm, through the skin
only, which it is then easy to push back to the vicinity of the articulation. A
second stroke divides all the tendons at the edge of the retracted teguments.
He then enters the articulation by one or the other of its sides, taking the cor-
responding styloid apophysis as a guide, and passing the bistoury in a line
convex towards the arm.
The radial and cubital arteries, which are easy to find and to tie or twist,
have often been left in the wound without precaution and without occasioning
\
198 NEW ELEMENTS OF
subsequent hemorrhage. As to the interosseal artery, it is too trifling to merit
any attention. If the operation has been properly performed, there will remain
enough of the integuments to enable the operator, without much effort, to bring
them forwards, and to cover completely the articular surfaces. It is here par-
ticularly, that Garengeot and Le Blanc recommend incision of the tendinous
sheaths to the extent of one or two inches, in order to avoid purulent collec-
tions. It is here too, that the depending posture of the stump seems to me to
be particularly indicated.
B. Flap Method. — 1st. Old Process. — The surgeons of the army have for a
long time, it appears, practised an operation, described by M. Gouraud in
1815, which consists in making upon the dorsal face of the wrist a semilunar
incision convex towards the fingers, and corresponding by its extremities with
the apophyses of the radius and the ulna. An assistant then withdraws the
cutaneous envelope. The operator divides the filaments which connect it with
the subjacent tissues, and with a second incision in the direction of the articu-
lation, severs all the extensor tendons and the posterior radio-carpal ligament.
He then cuts the lateral ligaments, the ten-dons of the posterior radialis, and
ulnaris muscles, if it has not already been done. It now remains to pass
through the joint with a narrow knife, which is brought in front of the carpus,
so as to finish by forming a flap of about an inch in length. Some surgeons
advise that this flap should be extended about two inches from its base, and
consequently cut it forwards at the expense of the thenar and hypothenar
eminences. When enough of the skin has been preserved at the commence-
ment, this precaution would be more disadvantageous than useful. In order
to cut the flap wdth facility, and to give it all possible regularity, the operator
should early incline the edge of the instrument towards the integuments, so as
to avoid coming in contact with the osseous protuberances of the carpus, and
to remove the pisiforme at the same time with the hand. As the flexor tendons
form here a considerable bundle, the operator should not hesitate, in case of
resistance, to pass the instrument beneath them, and to divide them trans-
versely. The coaptation of the lips of the incision cannot fail to be rendered
more easy. This process, equally prompt and simple, possesses the advantage
of permitting us, in case the soft parts behind are disorganized, to preserve
a sufficiency in front to close the whole division. It is still, however, subject
to the inconvenience of exposing the osseous angles to denudation, and oc-
casioning sometimes an overlapping of the lips of the wound ; for it is precisely
at the concave and least salient point of the articulation, that the thickest
and broadest parts of the flaps are applied.
2d. Process of M. Lisfranc. — The hand and the fore-arm are placed in
supination, and held so by the assistant, who at the same time compresses the
radial and ulnar arteries. The operator being provided with a narrow knife
pierces the tissue from the radius towards the ulna, or vice versa, according as
he may have to do with the right or the left wrist, opposite the styloid apo-
physes, passing thus between the soft parts and the anterior face of the carpus,
draws the instrument towards the hand, and cuts as in the preceding case a
semi-elliptical flap, about two inches long. This being drawn up, or turned back,
permits the surgeon to make immediately a semicircular incision upon the
dorsal face of the wrist, something like that which I have just described; to
divide at the same time the extensor tendons, almost to a level with the joint;
OPERATIVE SURGERY. 199
then to disarticulate^ by passing under the point of one of the styloid
apophyses, and to finish as in the circular method.
In attempting; to describe the process of Lisfranc>, the editors of Sabatier
have unwittingly introduced a slight modification. After having formed the
palmar flap, instead of carrying the knife behind the wrist in order to divide
the integuments, they advise to pass at once through the joint from the palmar
side, and finish by dividing the tissues which cover the back of the carpus,
f n either way this method presents nearly the same inconveniences and the
same advantages as the flap-method generally followed, from which it only
differs in circumstances too trivial to merit here a further discussion*
Art. 4. — The Fore-arm.
Anatomical and Surgical Remarks. — The law which requires us to am
putate at the greatest possible distance from the trunk, which is applicable to
every amputation performed on the thoracic member, is especially so in
regard to the fore-arm. J. L. Petit, Le Blanc, Bertrandi, and more recently,
M. Larrey, founding their opinions upon false appearances and upon
positions badly sustained, have however advanced the contrary. According
to them, the inferior third of that part is not sufficiently fleshy, encloses too
many fibrous tissues to permit the bone to be easily covered after amputation,
and a thousand dangers are incurred by making incisions there. The supe-
rior half, on the contrary, being furnished with numerous muscles, and
without tendons, presents the most advantageous conditions whicli could be
desired for the success of such operations, and should consequently be pre-
ferred at the risk of sacrificing some inches of tissue, which might perhaps be
otherwise preserved. To this reasoning it may be replied that, all circum-
stances being alike, the farther you operate from the root of the member the
less the fl^sh is divided, the less extensive the bleeding surface, the less
violent the general reaction, the fewer the accidents to be apprehended:
that the most meagre part of the fore-arm and the most completely devoid of
the muscular fibres, will always permit the operator to preserve a sufficiencr
of skin to meet and completely close the wound. I will repeat that when it
comes to the proof, it is always the integuments that form the cicatrix, and
that they are even better, more pliant, and more firm, when they are farthest
removed from tendons or muscles. But this is a question which experience
seems to have already and finally decided, for I do not see that any person
thinks of again bringing it under discussion.
Besides the twenty muscles and their tendons, the radial, cubital, and inter-
osseal arteries, with the corresponding nerves, and the median and the aponeu-
rosis and superficial veins, which are presented over its whole extent, the
fore-arm offers for consideration — 1st. Its two bones, movable one upon the
other, separated by a space diminishing as you approach either extremity, and
which by the assistance of a species of membraneous diaphragm, form the
floors of the anterior and posterior excavations or fossae. 2d. A series
of fibrous intersections and an abundance of lamellar tissue between the two
fleshy strata, the attachments of which permit but an inconsiderable retraction,
at the same time that the whole collection of these different objects could
lie NEW ELEMENTS OF
hardly have been made more favorable to the development of phlegmonous
inflammation and of purulent collections.
Manual — A. Circular Method. — All the varieties of the circular method,
that of Celsus, of Wiseman, and Pigraj, those of Petit, of Le Dran, or Louis,
of Alanson, and of Desault, have been or are still used in the amputation of
the fore-arm. That most generally followed at the present day, and in my
opinion, the best, is practised thus : —
1st. Process adopted by the Author. — The patient is supported on the edge
of his bed, or upon a chair, if he is not too much enfeebled. An assistant
stationed behind his shoulder presses the brachial artery against the humerus
below the arm -pit, with the four fingers of one hand, either directly or by the
intervention of a pledget or rolled bandage, whilst the thumb gives a counter-
support beneath, unless the operator should prefer the use of the tourniquet
or of the garot. A second assistant, or even the same if circumstances require
it, holds the fore-arm turned in pronation, and is ready at the proper moment
to draw the skin towards the elbow. The member to be removed, wrapped
in a linen bandage, should be supported by a tliird assistant. With the left
hand the operator, placed in front, takes hold of the fore-arm above tl^tj point
where the skin is to be incised if it be upon the left side, below, if on the^i&ght,
unless the operator be ambidexter. He then divides circularly the external
envelope to the aponeurosis, two or three fingers' breadths below the place
where the section of the bone is to be made. If any cellulo-fibrous filaments
hinder the retraction of the integuments, the operator divides them rapidly,
and immediately returns the knife with a circular sweep, as in the first
instance, upon the external and posterior face of the radius, cuts the whole
thickness of the flesh as near as possible to the retracted skin, first on the
dorsal region, then on the palmar, and in the third place on the radial. In
order to prevent their yfelding or slipping, instead of being cut it is necessary
that the instrument divide them with a sawing movement, without leaving the
surface of the radius until it rest fairly upon the ulna, which it should also
carefully graze as it passes round to the palmar side, if the operator desires
that no portion should escape him and present itself again behind. I need
not say that the same precaution is equally necessary for the rest of the cir-
cumference of the limb. The divided muscles retract more or less : the knife
is brought backwards upon the dorsal face of the cubitus, and then drawn
towards the operator ; its point glides upon the posterior interosseous fossae,
through which it is plunged deeply, and returns, dividing every thing it meets,
upon the posterior face of the radius around which it turns. It is then car-
ried beneath, in order to effect in front what has just been done on the back
of the member ; nothing then remains around the bones. The middle head
of the three-headed compress is immediately carried with the forceps through
the interosseous space, from the palmar to the dorsal side. The fleshy fai^
being thus protected and drawn back, the surgeon proceeds to divide tl^
bones ; begins with the radius, continues by operating at the same time upon
the radius and the ulna, but in such a manner as to finish with the latter.
After the removal of the part the triple compress is taken off", and the assistant
charged with the retraction of the soft parts immediately relaxes them. The
surgeon then occupies himself in searching for the arteries, one after the other,
in the midst of the tissues ; the anterior interosseal, accompanied by a iierve
OPERATIVE SURGERY. 201
which it is well to avoid, is found nearly upon the middle of the palmar face
of the ligament of the same name. The radial, situated more to the outside
and more superficially, is seen between the supinator longus, the flexor radi-
alis, and the flexor longus pollicis. It is so far removed from the nerve as
not to require, in this respect, any particular precaution in tying it. The
ulnar artery lies towards the inner side, between the flexor ulnaris, the flexor
sublimis, and the flexor profundus, having the nerve on its internal side. As
to the posterior interosseal artery, which is distributed throughout the fleshy
mass of the extensors, it needs no attention, unless the amputation have been
performed towards the superior half of the fore-arm. The wound should be
closed from behind and before, and it is in this direction that the adhesive
strips are to be applied. A transverse linear wound is thus formed, the angles
of which cover the bones and give exit to the remaining paits of the corre-
sponding ligatures, whilst that of the centre should be immediately brought
directly out at the middle of the wound.
2d. Process of Alanson, — If the skin were diseased, or had contracted
morbid adhesions with the subjacent tissues, it would be better, after having
made the incision, to dissect it up and turn it back upon its external face like
a rufile, after the manner of Alanson.
3d. Process of M. /. Cloquet. — When there is reason to apprehend soma
difficulty in dividing the muscles and tendons which lie in the interosseous
fossae, the surgeon may pass the knife flat between the bones and the flesh,
and immediately turn the edge so as to cut transversely outwards all the
soft parts on a level witli the retracted integuments, and that upon both
aspects of the limb successively. M. Hervez de Chegoin, I believe, first
published, in 1819, the idea of this modification, which M. J. Cloquet assures
us that he has applied many times with success; and which, through inad-
vertence no doubt, the editors of Sabatier have appropriated to themselves.
Remarks. — When all the muscles have been divided, some may desire to
cause them to retract so as to admit of sawing the bones at a higher point.
In this case they should detach for a few lines with the point of the knife, or
with the bistoury, the two edges of the interosseus membrane. Here, as
upon all the other parts of the member, we should preserve an extent of tegu-
ments the more considerable the higher we perform the operation; or rather,
the greater the volume of the part. It should be remembered too, that the
deep muscles which are attached to nearly the whole extent of the bones,
retract but little towards the elbow, and that we must depend principally
upon the skin for closing the wound and covering the stump.
B. Flap Method. — History and Appreciation. — The circular amputation of
the fore-arm generally succeeds extremely well, and admits of a cure in three
or four weeks ; yet surgeons have advised replacing it by the flap method.
M. Graefe, has in our own day performed it according to the advice of Ver-
duin and Lowdham, and as Ruysche declares that he had seen it performed
in his presence ; that is, by cutting a flap upon the palmar front of the limb,
and concluding the operation according to the circular method. Vermale,
Le Dran, Klein, Hennen, and Guthrie, prefer, on the contrary, to make two
flaps, one in front, and one behind. In this respect we can hardly refuse pre-
ference to the method followed by Vermale, over that of Verduin. I have tried
it myself, and have caused it to be performed by many of my pupils, upon
26
202 NEW ELEMENTS OF
the dead subject. I have twice operated in the same way upon the living
subject, and remain convinced that it is generally less advantageous than the
circular method, although the operation is more easy and more quickly finished.
It is very ti'ue, that it gives fleshy fibres to cover the ends of the bones. The
flaps are thick and abundantly furnished with cellular tissue, to fit together
exactly, and to provide with certainty for all the exigencies of immediate
union. Two inches are sufficient for each, in order to enable them properly
to meet ; if the disease extends farther upon one side than the other, it is
easy to make but one flap, or two of unequal length ; so that it cannot at first
be seen why this method would not permit amputation as low as the circular
method. Unfortunately, in looking more closely, it will sw)n be perceived,
that these advantages are illusory ; all the muscles are cut obliquely, and
this necessarily increases the traumatic surface. They are preserved in the
thickness of each flap, only to increase the danger of inflammations which
may then develop themselves. The bones a^e not the less exposed to escape
by the angles of the solution, and the slightest reflection will show, that by
a circular incision an inch of teguments will close with more exactness a
wound two inches across, than flaps half as long again, because of the open-
ing which the flaps are so prone to leave upon each side of their base : never-
theless, here is a manual of the operation.
2d. Manual. — The limb is turned in pronation, and held in a convenient posi
tion. The operator cuts the palmar flap, by passing his knife from one side of
the fore -arm to the other between the bones and the soft parts, which he
divides obliquely towards the wrist. In order to form the dorsal flap, he draws
the lips of the wound backwards, returns the point of the knife to the supe-
rior part of the first incision, passes it behind the bones, and finishes with
the same precautions as before. He then directs the assistant to turn back
immediately all the fleshy parts, cuts around the radius and the ulna, and
with the assistance of the divided compress divides these bones as directed in
tlie circular operation.
3d. Remarks, — Cutting the anterior flap first allows a greater thickness to the
dorsal, and as the palmar side of the fore-arm is turned downwards, the blood
which at first escapes does not at all interfere with the rest of the operation ;
but this precaution is far from being indispensable. The important point is to
obtain two flaps of nearly equal dimensions, and to avoid cutting them out too
much at the angles. The operator may also leave the limb in supination
instead of turning it after the first stroke into pronation, but then the division
of the bones will produce a greater degree of motion in the joints, and cannot
be so easily effected. It is recommended to saw the radius and the ulna toge-
ther, so as to finish upon the latter, because, in being connected more firmly
to the humerus, the ulna gives a better support to the action of the saw. In
advising the operator to place himself in front between the limb and the trunk,
I have not intended to establish a general rule. Garengeot positively advises
the contrary ; and Bertrandi adds, that in case the patient is in bed, the opera-
tor would be improperly situated, at least on the right, if he did not place
himself on the outside. The English and German surgeons, Mr. Guthrie
amongst others, are wrong in saying, that amputation by flaps is only appli-
cable to the superior part of the fore-arm; it is applicable to any point of its
length. Le Dran remarks that a subject upon whom he operated in this manner.
OPEilATrVE SURGERY. SOS
was cured in twenty days, whilst by the circulai* method he did not obtain
cicatrization until the expiration of two or three months; but there is nothing
astonishing in this, since they did not in his time attempt union by first inten-
tion after circular amputation.
Art. 5.-^The Elbow,
History and Appreciation. — Some surgeons of the last century, founding
their opinions upon a passage of Pare, who says that he had ventured to dis-
articulate a fore-arm gangrened after fracture, have thought that this operation
would be of considerable advantage in practice ; amongst others, that of pre-
serving to the limb three or four inches more in length than by amputating
the arm itself. Many of the moderns have objected that this advantage is
one of too slight importance to be purchased at the price of such numerous
difficulties and dangers of every description which accompany such a disar-
ticulation. If it is possible to cut in the soft parts a flap long enough to
cover completely the articular extremity of the humerus, circular amputation
immediately before the joint must be equally practicable. In the contrary
case, say these objectors, one could not decide upon leaving such a large carti-
laginous surface uncovered, and the amputation of the arm becomes indispen-
sable. These arguments are less conclusive than they at first appeared to be ;
even if the fleshy parts are in such a state that they can be preserved, it does
not follow that the bones are sound to the point where the saw must be applied to
preserve the smallest fragment. Necrosis, caries, comminutive fractures,
&c. may extend themselves as far as the articulation, without the surrounding
tissues losing entirely their primitive characters; the diseased bones then
being once removed, who does not know that the soft parts the most deeply
affected, often return at last to their natural state. Besides, the operation which
is in fact less dangerous in itself than the amputation of the arm, is far from
being so difficult as some have imagined. Dr. Rodgers, of New York, has prac-
tised it with success, and M. Dupuytren has foand no reason to condemn it.
For my own part, I believe it to be indicated in every instance where the alter-
ation of the bone approaches within an inch or two of the articulation.
Manual. — Ambroise Pare, who was conducted by circumstances, or pressed
by necessity to the performance of this operation, has not, or has at least but
very vaguely described his method, supposing no doubt that every one could
guess it and imitate it.
A. Flap Method. — 1st. Process of Brasdor. — After several trials Brasdor
came at last to the following precepts : — An incision in shape of a half-moon
with its convexity downwards compressing the posterior half of the circum-
ference of the member, is first made a few lines beneath the summit of the
olecranon, so as to admit of the division of the latter ligaments and the ten-
don of the triceps, and to open freely into the articulation of the radius. The
knife being passed flatwise from one side to the other, between the anterior
face of the bones and the fleshy parts, then forms a large flap, of which the
base corresponds with the joint, and the free end comes about three or four
inches below. Finally the operator concludes by disarticulating the ulna in
the direction from the coronoid process to the olecranon, and by the division of
the triceps when it has not been effected before.
204 NEW ELEMENTS OF
2d. Process of M, Vacquier, — M. Vacquier proposes to modify as follows,
the process of Brasdor : — With a two-edged knife he begins by cutting the ante-
rior flap from below upwards, as far as the articulation ; cuts tlie ligaments
which unite the radius and the ulna to the humerus ; luxes the fore-arm ; and
closes by detaching the olecranon from the large tendon to which it gives
attachment, and from the teguments, so as to leave a flap some lines in length
behind.
3d. Process of Sabatier. — Sabatier ascribes to M. Dupuytren the suggestion
that it is much better to saw off" the olecranon and leave it attached, to form
the flap after the manner of Faye, in amputation of the shoulder, or that of
Verduin, for the amputation of the leg, than to follow to .the letter the advice
of M. Vacquier.
4th. Process of M. Dupuytren. — According to M. Sanson and Begin, M.
Dupuyti'en has in seven or eight instances practised the amputation of the
elbow with success, according to the manner of Verduin ; that is to say, by
plunging a two-edged knife in front of the articulation, from one condyle of
the humerus to the other ; between the bones, which he grazes with the knife,
and the soft parts, which he holds up in the left hand, and then divides them
from above downwards. The disarticulation being eff*ected, M. Dupuytren
completes the operation by sawing or removing the olecranon.
5th. Process of the Author. — I do not see any advantage in preserving the
olecranon, as advised by Sabatier and frequently done by M. Dupuytren. The
triceps has no occasion for it in order to move the humerus, and it is evident
that its presence cannot favor in any degree the success of the operation. In
order that the saw may act upon its anterior face, it is necessary that the arti-
cular surfaces should be completely dislocated. There can then be no diffi-
culty in detaching it from the teguments which cover it behind. But supposing
that the operator is bent on preserving it, the following modification appears
to me to offer some advantages ; — An anterior flap is formed after the manner
of M. Dupuytren, but a little lower down than directed by that operator. The
integuments which remain behind are then divided as in the circular method,
at about an inch below the epicondyles. The operator then cuts the external
lateral lijijament and disarticulates the radius, and after having exactly incised
all the soft parts which surround the ulna, he saws through it immediately
beneath the coronoid process as near as possible to the joint, in the line of the
humero-radial articulation. He thus avoids all the difficulties of the disarti-
culation of the elbow ; the operation is as prompt as that by any other method ;
there is no occasion to exert any traction or wrenching upon the bones ; and
the wound, which is sensibly less, is necessarily less disposed to suppurate, and
admits more easily of immediate union.
B. Circular Method. — I have arrived at the conviction that the circular
mode of amputation here off*ers undeniable advantages. An inch of inte-
guments preserved below the elbow would suffice to cover the humeral trochlea,
while by the flap method three or four are required in front. As all the
muscles are removed, the incision must in reality be much smaller and less
exposed to profuse suppuration, and would not occasion such a lively reaction.
After having divided the skin circularly, I dissect it and turn it back as far up
as the joint, after which I cut the anterior muscles, then the lateral ligaments,
in order to disarticulate from front to rear, and close with the division of the
OPERATIVE SURGERY. 205
triceps. The humeral artery is the only one that requires to be tied or twisted,
and the ruffle of skin may be turned forwards without the least difficulty to
close the wound.
Art, 6.-^The Arm.
As the amputation of the arm is most frequently required by a disease of the
humero-cubital articulation, it is generally performed below the middle of the
limb. But other aifections, such as injuries to the arm itself, sometimes
require this operation to be performed nearer to the shoulder.
Anatomical Remarks. — The only bone which enters into the constitution of
the arm is cylindrical in its centre ; slightly turned upon its own axis ; flat-
tened so as to present its edges bare beneath the skin, near the elbow ; and
surrounded by numerous muscles. The deltoides, the coraco-brachialis, the
long heads of the triceps and the biceps which are also attached to the scapula,
the pectoralis major, and the latissimus dorsi, form a distinct system, the re-
traction of which should be expected when amputation is performed above the
deltoidean muscles. As they are all inserted below the head of the humerus,
M. Larrey has concluded that in amputating at the surgical neck of the bone,
the fragment which is preserved can be of no avail ; that it is even incon-
venient, since the supra and infra spinati muscles hold it in a state of permanent
extension. Below the deltoid muscle, the biceps which extends without inter-
mediate attachment from the shoulder to the fore-arm, is the only one which can
retract itself to any considerable extent, after having been cut. The others, the
brachial and the three connected portions of the triceps, having their fibres
attached to the humerus itself, can withdraw themselves but very slightly from
the point where they have been divided by the knife.
Manual. — A. Circular Method. — If with Petit, after having incised and raised
the skin, we content ourselves with dividing all the muscles at a single stroke
on the point where the saw is to be applied in the inferior half of the arm, the
biceps muscle will rarely fail by its consecutive retraction to produce the
denudation of the bone. The teguments are too movable upon the aponeu
rosis to require that we should dissect and turn them out, as advised by Alan
son. There remain for choice then, the process of Celsus or of Louis, modified
by M. Dupuytren, and that of Desault.
The patient being placed and the artery compressed as for the amputation
of the fore-arm, an assistant holds the limbs apart from the trunk at nearly
aright angle. The rule requires that the surgeon should place himself on the
outside, but when he operates on the left arm, there is some advantage to be
gained by placing himself on tlie inside. The left hand of the surgeon is thus
still enabled to draw the skin as the instrument divides it. The section of the
integuments is then performed as near as possible to the elbow. In incising
the muscles circularly at the edge of the retracted skin, it is very important
to traverse the whole thickness of the biceps muscle. It might even be cut
alone in the first instance, as is done by Mr. S. Cooper, so as not to touch those
of the deep stratum, except at a few lines from the point where the section of
the bone is to be made. When the humerus has been exposed, it can do no
harm to separate from it the fleshy fibres parallel to its length to the extent
of one or two inches, as advised by Bell, Mid as now practised by M. Graefe.
in*
206 NEW ELEMENTS OF
M. Hello contends that these deep fibres, thus preserved, are the only ones
which can really apply themselves to the end of the bone. I would add the
necessity of dissecting the skin, according to Alanson, if all the other tissues
are to be cut perpendicularly upon the bone at a single stroke. In every way
care should be taken that the radial nerve do not escape the edge of tlie knife.
The lasf fleshy stratum should be divided about three inches above the
incision in the skin ; the retractor and the division of the bone present nothing
peculiar.
The humeral artery is found between the biceps and the internal portion of
the triceps muscle, closely attached to the median nerve, and between its two
attending veins. Two or three branches which here merit some attention,
discover their position by the blood wliich jets from them. Above the deltoid
depression, the biceps muscle being brought nearer to its origin, cannot with-
draw itself to the same extent, but as the volume of the muscles is much more
considerable, it is not less indispensable here than below to preserve as much
of the skin, and to favor the retraction of the muscles as much as possible
before sawing the bone.
De la Faye had before advanced, and Le Blanc had already disputed the
opinion defended by M. Larrey in his Memoirs of Military Surgery, that it
is more advantageous to disarticulate the humerus, than to divide it above the
muscles by which it is connected with the chest. But the question has been
decided in favor of Le Blanc and of M. Richerand. Experience has proved
that after the cure, the deltoid, the pectoralis major and latissimus dorsi, the
teres major and coraco-brachialis muscles, are not without action upon this
little end of hone, as it is termed by De la Faye, and that they can impress
different motions upon the stump. The little which is left of the arm in-
creases at least the projection of the shoulder, opposes the sliding of the
clothes, preserves the hollow of the axilla, most frequently enables the subject
to hold against the breast some foreign bodies, such, for instance, as a cane,
a port-folio, or the like ; besides it is not necessary to open the articulation,
nor to fill up the large cul-de-sac which exists between the acromion process
and the scapular tendon of the triceps muscle.
J B. Flap Method, — The arm is the limb which appears to be the least
adapted to the flap method, inasmuch as its round form, the disposition and
the small size of its bone, tend greatly to the success of the circular method.
Klein and M. Langenbeck have nevertheless endeavored to bring it into vogue.
I have myself had recourse to it twice upon the living, and have practised and
caused it to be practised many times upon the dead subject. At the first
glance it seems as if the operator would be enabled to derive from it a great
advantage in reference to immediate union. By it, it is not only the skin, as
in the circular method, but the muscles besides that cover the extremity of the
bone and close the wound. The operator has then nothing to fear from the
retraction of fleshy fibres nor from the isolation of the skin : three strokes
with the knife, one for each flap the other to denude the bone, and one with
the saw, suffice to complete the operation. Of all these advantages, promp-
titude and facility are the only ones of real value. The mass of muscles to
which 80 much consequence is attached, only favors the development of
phlegmonous inflammation in the stump, tends continually to slide to one side
or the other, and upon the slightest suppuration to expose the bone at one of the
OPERATIVE SURGERY. 207
angles of the wound. In no other place are the inconveniences of the flap
method so manifest : but Sabatier himself recommends it when it is necessary
to amputate near the shoulder.
1st. Process of Klein. — A narrow knife plunged through from the radial to
the cubital side, grazing the bone, cuts a semilunar flap of about three inches
in length. After having formed a second in the same manner on the opposite
side, the operator causes the two to be held back, and incises at their base
what few fibres still adhere to the bone which he saws with the ordinary
precautions.
2d. Process of M. Langenbeck. — The assistant forcibly draws upon the
integuments. The operator being on the inside, supports with the left hand
if operating on the right arm, and vice versa if on the left arm, the inferior part
of the member; with the other hand, armed with a good knife, he cuts
with a blow from the skin to the bone an internal flap, which should be as in
the preceding case of two or three inches in length ; then passing the knife
and the wrist beneath and returning them to the front of the arm, he is in a
position to form an external flap similar to the first. I have seen young
German surgeons practise this operation in our amphitheatres with the greatest
celerity ; but such trick of strength or of address, can only be valuable in the
eyes of those who, like the pupils of Langenbeck and of Graefe, are for him
that operates the most quickly, and who counts the seconds in amputations.
3d. Process of Sabatier. — Sabatier only recommends tlie flap method where
the operation is performed too high to permit the use of the tourniquet. His
process, as already described by Le Blanc, consists in making, by means of one
transverse and two longitudinal incisions, a flap in the form of a trapezium,
at the expense of the anterior external part of the deltoides, raising this flap,
and by a circular incision cutting the rest of the soft parts before passing to
the division of the bone. It will suggest itself to every one that, in this case,
as in all others where amputation is performed near the shoulder, compression
should be applied to the artery above the clavicle, or upon tlie second rib, in
the manner which I will describe below.
*^rt, 7. — The Arm at the Joint,
It is an error to believe that, up to the commencement of the last century,
no one had dared to disarticulate the arm. Laroque reports an instance of
this operation in 1686 — the member had fallen into gangrene : *' The surgeon
took a small saw to amputate the humerus, but perceiving that it wavered
towards its articulation with the shoulder, he gave it a little jerk and the bone
easily came out of its socket, after which the boy was speedily restored to his
former health." Although the idea must have frequently presented itself to
the minds of the surgeons, the fear of opening an articulation of such mag-
nitude, the want of means to suspend the course of the blood in the limb
during the operation, and the proximity of the trunk, had kept off" the boldest
practitioners. Le Dran is the first to have described it : his father had had
recourse to it in a case of necrosis of the humerus, attended with profuse sup-
puration, and effected a complete cure. It has been since pretended that the
elder Morand had performed this operation before Le Dran, but without suf-
ficient proof. At the present day the advantages of this amputation are rc
208 NEW ELEMENTS OF
longer disputed, and it has been so often performed that it is unnecessary to
discuss its possibility.
Anatomical Remarks. — The articulation of the shoulder is overtopped by
two processes which pass in front of its line, and which increase in an especial
manner its vertical diameter. It consequently presents a disposition much
more favorable to coaptation of the amputatory wound, transversely than ver-
tically. The head of the humerus forms a very obtuse angle with the body
of that bone, and the fibrous capsule is attached a little beyond its limits. At
the time of amputation, the edge of the knife must describe a circular line
exactly corresponding to the plan of this head, in order to divide with ease the
fibrous tissues. The glenoid cavity, crowned with a fibro-cartilaginous ridge,
is itself longer in a vertical line than horizontally ; and this disproportion is
apparently increased by the fossa formed by the two above* mentioned pro-
cesses of the scapula. In proceeding downwards v/e find about this articu-
lation (beneath the common integuments and a very fine aponeurotic lamina),
the deltoid muscle, a loose cellular stratum, the tendons of the supra-spinatus,
of the infra-spinatus, of the sub-scapularis, the teres minor, and inclosed within
them the fibrous capsule and the long tendon of the biceps ; to the inside, the
coraco-brachialis and the short head of the biceps muscle; lower down, the
scapular head of the triceps; then the brachial plexus, the axillary vessels,
and under the skin the pectoralis major, and the longissimus dorsi and teres
major. Several of these objects may be easily recognized from without: thus
the summit of the acromion is perceived above the projection of the shoulder,
and seems continuous on the inside with the clavicle ; and the coracoid, a little
nearer to the breast and more prominent, is also easily discovered. There
too is a triangular space of which we may avail ourselves in practice. It is
bounded on the outside and below by the head of the humerus, above by the
clavicle and the acromion, on the thoracic side by the coracoid process. This
space leads directly to the articulation, and has served as a guide to M.
Lisfranc in the execution of one of his operations. The posterior border of
the arm-pit being raised and turned outwards upon the scapula, permits us
to arrive beneath the acromion and to traverse the outer and upper part of the
articulation. The acromion is much more prominent upon some subjects than
upon others ; at times also its anterior border is very low, so that its humeral
face presents a very deep concavity^ In infancy it remains long cartila-
ginous. Upon two adult subjects I have been able to separate it with a slight
effort, as an epiphysis of the spine of the scapula. These different anomalies
being capable of rendering the disarticulation of the arm either more easy or
more embarrassing, should be always present to the mind of the operator, as
well as the other anatomical details which I have just given.
§ 1. Manual,
The amputation of the arm in the articulation is one of those which offers
the greatest number of operative processes. Every surgeon who has performed
it, has believed himself bound to invent a new one ; they have brought into
use the circular, flap, and oval methods, and all the varieties of which these
several general methods would admit.
A. Circular Method, — The idea of applying the circular method to the dis-
^^ OJ^ERATIVE SUROEltY* 209
articulation of the arm was not, as M. Blandin believes, suggested by the
author of the iEirticle Amputation in the Encyclopedia. iSarengeot expressly
declares, that in his time it was preferred by many persons ; Bertrandi like-
wise mentions and condemns it. Alanson described it iil 1774 ; and advises
that the muscles should be cut obliquely, as in the amputation of the thigh.
1st. Old Process. — The phrase of Garengeot implies the simple circular
method. The artery being compressed upon the first rib and the fleshy
parts drawn up by the assistant, the operator incises successively the integu-
ments and the muscles as far as the bone; coilimiencing at three fingers'
breadth below the acromion. A final stroke of the knife detaches the head of
the humerus from the glenoides cavity, and terminates the operation.
2d. Process described by Bertrandi, — A large convex bistoury divides trans-
versely the mass of the deltoides on its dorsal face at some distance from the
acromion, arrives upon the biceps muscle, opens the capsula, passes behind the
head of the humerus after having dislocated it, and finishes the division of
the soft parts with that of the posterior half of the limb.
3d. M. Cornuau, formerly a pupil of the military hospitals, has proposed
in his thesis a process, founded upon the same principles as the preceding.
The skin being divided at four fingers' breadth from the acromion, and
drawn up by Sie assistant, the operator passes to the division of the fleshy
parts, which he effects by a single stroke carried transversely from the coraco-
brachialis as far as the tendon of the teres major, causes them to be drawn up,
opens the articulation and passes through it from above, grazes the neck of
the humerus, and terminates by a second transverse incision which connects
the two extremities of the first, comprehends the vessels, and completes the
circular incision.
4th. Process of Alanson and of M, Grsefe. — That of Alanson presents no
peculiar feature. M. Graefe, however, in order to form a hollow cone with
the base downwards at the expense of the muscles, uses the wide point of a
knife terminating in the point of a shield.
5th. Process of the *^uthor, — I have repeated all the varieties of the circular
method upon the cadaver, and I have found that no other is more prompt, or
affords an incision more regular, and more easy to unite immediately. The
process which appears to me to embrace the most advantages, consists in dis-
secting and raising the skin, without touching the vessels, to the extent of
two inches ; then cutting the muscles after the manner of M. Cornuau asSp^
near as possible to the articulation, through which the knife is immediately
passed, and finishes with the division of the triceps and of the vascular packet,
the root of which has been previously seized by an assistant.
B. Flap Method, — ^The different processes which come under the flap
method, may be arranged in two classes ; from the one results a transverse
wound, the other produces a wound the greater diameter of which is vertical.
1st. Transverse Method,— Ea.ch of these two classes forms, in some sort, a
particular method, the respective advantages and inconveniences of which
should be carefully appreciated. The first has been for a long time the only
one employed, and includes tlie processes of Le Dran, Garengeot, de la Faye,
M. Dupuytren, M. Lisfranc, and others.
a. Process of Le Dran. — The patient is seated on a chair ; the assistant
seizes the arm, and holds it moderately extended from the trunk. With a
27
210 NEW ELEMENTS OF
narrow knife the surgeon incises transversely the deltoides, the two heads of
the biceps a little in front of the acromion, then the tendons which attach
themselves to the head of the humerus, and the fibrous capsule. Whilst the
assistant sways the arm and disjoints the extremity upwards, the surgeon,
keeping the knife in a transverse position, passes through the articulation,
slides the instrument behind and cuts a flap of three or four inches at the
expense of the fleshy parts of the posterior portion of the limb, and comprising
the nervous plexus, the vessels, the borders of the axilla, and various muscles.
b. Process of Garengeot. — The mode of Garengeot differs in three points
from that of Le Dran. Instead of a straight needle, he advises a curved one,
which is passed from front to rear through the flesh, grazing the neck of the
humerus, so as to compress the artery. He recommends to make the first
incision at three fingers' breadth from the acromion, in order to form an upper
flap at the expense of the deltoid. Finally, in finishing, according to Le Dran,
with an axillary flap, he allows it less length and cuts it square, so that it may
better fit the deltoid flap.
c. Process of La Faye. — La Faye makes no previous ligature and cuts
but one flap ; but instead of leaving it below he forms it above, in the form of
a trapezium. A transverse incision is first made above the inferior attach-
ment of the deltoid muscle, at about four fingers' breadth from the summit
of the acromion. Two other incisions which he then commences, the one on
the inside, the other on the outside of that process, are made in the direction
of the fleshy fibres to meet the corresponding extremities of the first ; the flap
dissected and raised up, permits the opening of the articulation, the dislocation
of the humerus, the exposure of the soft part of the axilla, and the ligature of
the artery, before detaching the arm from the ti-unk.
d. Process of M, Dupuytren, — In a thesis sustained in 1803, M. Grobois
advises the following modification of the process of La Faye : — With one
hand the operator takes up the whole thickness of the parts which should form
the superior flap ; with the other he pierces them at the base of the deltoid
with a small knife held horizontally, the edge of which should be directed in
front ; he then cuts the flap by drawing the instrument outwards and forwards,
taking care to allow it a suflicient length. M. Grobois speaks of this modifi-
cation as of a thing which belonged to him, and of which he had thought a long
time before. But it is probable that he derived the idea from the lectures of
M. Dupuytren, for it is under the name of this professor that the process is
generally known.
e. Process of M. Onsenort. — Instead of being formed from the deeper parts
to the skin, the deltoid flap may be cut in the opposite direction ; that is,
from the integuments towards the articulation, from its apex towards its base,
assuming as before a semilunar form. This manner, which does not sensibly
differ from that of Garengeot, is yet by some pupils attributed to M. Dupuytren.
I have seen M. Dubled and Guersent, junior, practise it upon a dead body
with great address, and M. Onsenort exerted himself, in 1825, to bring forward
its advantages. Mr. Cline, of London, begins by compressing the artery upon
the first rib ; then with a narrow knife he makes, at the expense of the deltoid,
a flap capable of covering the wound, passes through the articulation, and
divides at a single stroke the muscles which unite the arm to the shoulder and
the trunk. Tins process, which the surgeon of London has practised for a
OPr.KATIVE SURGERY. 211
long time, is described by Dr. Smith (ia Dorsej's work) in a manner ex-
tremely obscure, but it very mucli resembles the preceding ; and I can say
that in practising it according to this idea, I found that the operation could
easily be performed with a rapidity which it is difficult to conceive.
/. Process of M. Lisfranc and Champesme. — M. Grobois had already
suggested that another advantage would be derived from his modification
of the process of La Faye, by contriving to open the superior part of the
articular capsule at the first stroke. M. Lisfranc and Champesme have
made this remark the foundation of a new process. The arm with the elbow
somewhat near the trunk, is carried in this position upwards and outwards.
The operator being placed in front of the shoulder, applies the point of the
knife to the triangular space which has been above described, one of the edges
being directed upwards and forwards ; plunges it through the soft parts and
through the articulation outwards and backwards and downwards, so as to
bring it out at about an inch beliind the acromion ; seizes the deltoides, raises
it with one hand, cuts forwards and slightly upwards, turns round the supe-
rior part of the head of the humerus, and gradually brings the edge of the
instrument to a direction nearly horizontal ; sways the arm from the trunk
about fifteen or twenty degrees as soon as he has cut about an inch, and
finishes the flap as in the processes of M. Grobois and Dupuytren.
g. Bell begins by a circular incision four inches below the joint, then makes
a longitudinal incision on each side so as to form two flaps after the manner
of Ravaton, dissects and raises these flaps, and finishes with the disarticu-
lation. Of all these methods, the most prompt and simple is that of Mr.
Cline or Onsenort; but then it is difiicult to give to the superior flap the full
extent desired. That of M. Lisfranc, which follows next, would be still more
prompt if in performing it unpracticed surgeons did not run the risk of
striking against the head of the humerus or of the acromion with the point
of the knife : there is besides a risk of forming a flap much too narrow at its
base. It is evident that if we are content with one flap aboye, the process
of Dupuytren or that of Lisfranc is preferable to the three incisions of
La Faye.
2d. Vertical Method. — To the second class belong all those processes which
aim to place the flap before or behind, or to form one in each of these situations.
a. Process of Sharp. — The first process in the list which we are now to
begin is that of Sharp. This author first incises the skin, the deltoides, and
tlie great pectoral muscle, from the summit of the acromion to the hollow of
the arm-pit, in such a way as to expose the vessels and to afford an opportu-
nity of tying them. He then passes through the articulation from within
outwards, and finishes by cutting the soft parts of the opposite side, so as to
preserve as much of the skin as possible.
b. The Process of Bromfield is too complicated and too long to merit a
description now, although it belongs properly to the vertical method.
c. Process of Pojet. — ^Pojet, in a thesis upon the disarticulation of the
arm, proposes to make a longitudinal incision from the summit of the acromion
to the vicinity of the humeral insertion of the deltoid, to remove the lips of the
incision so as to cut the articular capsula and the tendons which surround it;
to lux the head of the bone, and finish by sliding the knife between it and the
flesh and cutting downwards.
212 NEW ELEMENTS OF
A process nearly analogous to this has met with complete success in the
hands of Dr. Dorsey of Philadelphia.
d. Instead of belonging to the circular method, the process described by
Petit-Radelf in the Encyclopedia, is nothing more than that of Bell, modified
in such a manner that one of the flaps is on the inside, the other on the
outside.
e. Process of Desault. — The member is held between the state of extension
and that of flexion, and is directed slightly forwards. The surgeon clasps
with one hand the fleshy parts of the shoulder, traverses them downwards and
backwards with a narrow knife, grazing the head of the humerus ; forms an
internal lambeau three or four inches long, which includes the anterior side
of the axilla, the vessels and the nerves, and which the assistant raises imme-
diately, so that the operator may pass through the joint from front to rear, or
from within outwards, and finish by forming a posterior or external flap
similar to the first.
/. Process of M. Larrey. — In operating according to Desault, you divide
the artery at the first stroke, and that may occasion'serious accidents, if from
any reason the amputation cannot be promptly finished. M. Larrey thought
it better to begin with the posterior flap, to open the joint from the outside,
and to finish with the internal flap.
g. Another process of M, Larrey. — ^M. Larrey, who has so often performed
this disarticulation in the army, describes another process for effecting it, to
which he ascribes great advantages. He cuts at first through the whole
thickness of the cushion of the shoulder, in the direction of the fibres of the
deltoid, and to the extent of four inches, as in the process of Pojet. He causes
an assistant to draw asunder the lips of this incision, to the upper end of
which he again applies his knife, and pushes it through from above downwards,
so as to make it emerge in front of the posterior edge of the axilla, and cuts
from this beginning the posterior flap. He comes back to the same point as at
first, and cuts in the same way an anterior flap; leaving between the two the soft
parts which fill up the cavity of the axilla, so as to save as yet the artery and
the nervous plexus. He then divides the deep seated tendons and the capsule ;
passes through the articulation, glides the knife behind the head and neck of
the humerus, and finishes by dividing the pedicle between the basis of the
flaps. Hence results a wound of nearly an oval shape.
h. Process of M. Dupuytren. — M. Dupuytren forms the posterior flap by
cutting from the surface inwards, from its apex to its base, and then com-
pletes the operation in the same way as M. Larrey.
i. Process of M. Delpech. — If you neglect to form a posterior flap, or give
it but little length ; if you fall almost immediately upon the external face of
the articulation to open it, pass through it, and finish by forming a large in-
ternal flap, you have the process of M. Delpech.
j, M. Hello first cuts a superior flap, like M. Dupuytren, and then carries
the knife between the shoulder and the chest, to finish the operation upon the
principles of the circular method.
This process, says he, which was followed by M. Fouilloy, is particularly
applicable where the humerus is broken up, or when displaced fragments of
bone render the formation of any kind of flap by puncture more difficult than
usual.
OPERATIVE SURGERY. 213
k. Process of M. Lisfranc. — To avoid the reproach cast upon his first
process w^ithout sacrificing its advantages, M. Lisfranc has the arm mode-
rately extended from the trunk ; places himself on the outside ; applies the
point of a long knife in front of the posterior border of the axilla, as if to raise
this border and push it back ; passes through the whole thickness of the soft
parts, and through the articulation upwards and forwards, bringing out the
point very near the anterior edge of the acromion, between that process and the
carocoid ; begins to cut outwards ; raises the arm a little, and inclines it a
little backwards ; turns with the blade round the posterior and superior half
of the head of the humerus, and cuts from there his posterior flap ; returns to
the joint, and finishes like M. Dupuytren or M. Delpech.
C. Oval Method. — It would be easy to discover the origin of the oval
method in the processes of Sharp, Pojet, Bromfield and Larrey. At all events,
it does not belong to Beclard, to whom it is ascribed in this country, nor to
Guthrie, who was the first to describe it in England. I have seen it distinctly
announced in several theses of the school of Strasburg, particularly in that
of M. Blandin, defended in 1803, and still more clearly in that of M. Chasley,
who even uses the word ovalaire to designate the form of the wound. The
several processes which it admits differs but little from each other. — Mr,
Guthrie forms a V, by means of two incisions extending from the acromion to
the opposite sides of the axilla close to the chest ; cutting the skin first and
the flesh afterwards. Beclard and M. Dupuytren cut at once to the bone, but
in both processes the incision should be somewhat convex forwards, and quite
superficial below, to save the vessels until after the disarticulation. Prepa-
ratory to this is the detachment of the point of the V by a third stroke. The
base is cut oft' by the last stroke. M. Scoutetten varies from this process only
in bringing the internal incision to the edge of the axilla, and with a continu-
ous motion carrying it across that space and up on the outside to the point of
departure, taking care in passing the axilla to cut only the skin.
Process adopted by the Author. — First Stage. — As the muscular fibres are
cut near their origin, and their retraction cannot be considerable, it is right to
imitate Mr. Guthrie in first cutting the skin alone, and causing it to be drawn
back if tlie shoulder is covered with much flesh, otherwise it is well enough
to cut at once to the bone. Second Stage. — The point of delicacy in the oval
method is the opening of the capsule ; if the bistoury penetrates too deeply, the
fibrous pouch yields and folds itself like a wet cloth, and is mashed rather
than cut : if it fall without the surgical neck of the bone, the ligamentous
connexions are but imperfectly destroyed. To obviate this difficulty, the
surgeon, while the lips of the wound are held apart, should seize the arm with
one hand and make the head of the bone project, turning it inwards at the
same time on its axis ; carry a sharp bistoury flatwise between it and the flesh,
and then turn its edge at right angles upon the capsule at the level of the sur-
gical neck of the bone, and then cut with the full edge all the tendons, begin-
ning with the teres minor and ending with the subscapularis, taking care to let
nothing escape ; to take the head of the bone for the support of the incision,
and to roll it on its axis in one direction as the instrument is drawn on the
other. In this way the articulation is freely opened and the arm is easily dislo-
cated, permitting the division of the rest of the capsule by the bistoury car-
ried in front, behind, and within, as if to shave the bone. In the third stage, the
214 NEW ELEMENTS OF
assistant, behind the shoulder, puts his thumb upon the artery in front of
the glenoid cavity, and compresses it in the mass of flesh left between
the lower exti'emities of the incisions already made ; while with a small knife,
or even with the same bistoury which has served him thus far, the surgeon
cuts through the base of the V, and completes the separation of the member
from the trunk.
;§ 2. Comparison of the different Methods,
In all fiiese processes it is necessary to suspend for a time the course of
blood. Of the various modes of effecting this, that of Le Dran or Garengeot
is uncertain ; that of La Faye and others almost necessarily includes in the
ligature parts which should be avoided ; that of Sharp increases the sufferings
of the patient and the length of the operation. The compression upon the first
rib is not always applicable, and if imperfectly applied, endangers fatal
hemorrhage. A method more sure and simple is to divide last of all the parts
which contain the vessels. The preparatory ligature of the siibclavian, which
has been performed by Dr. A. H. Stevens, in 1821, cannot be required except
by very considerable deformity. I do not know who first proposed the mode
which I have recommended ; but it was not until within twenty years that it
was, upon the recommendation of M. Richerand, generally adopted. The other
arteries which it is sometimes useful to tie, are the acromial, the external thora-
cics, the circumflexes, and some branches of the subscapnlaris. These are not
commonly tied until after the axillary, but if they bleed profusely, or if any-
tliing prevents the iminediate completion of the operation, they may be easily
tied as fast as they are divided.
In so many different processes, there is no one which merits an exclusive
preference ; no one that will not arrive at the end proposed ; nor any which has
tiot its peculiar cases to which it is better adapted than any other. The choice
should be decided by the circumstances of the disease ; stich as its proximity
to the joint ; its greater advances on this or that side, or above or below ; the
degree of motion it allows to the joint, or the position in which it arrests the
limbs. But it is at the bedside that the skillful surgeon should appreciate
these various exigencies.
But then supposing that nothing in the state of the parts obliges us to con-
form to any one mode rather than another, what method presents the greatest
advantages ? Those which leave a transverse wound leave also too great a
cavity between the acromion and the inferior border of the glenoid cavity.
The celerity of M. Lisfranc's second method leaves nothing to be desired in
that respect. That of Desault, modified by MM. Larrey and Dupuytren,
requires but little more time"; but the oval method, as furnishing a wound
incomparably more regular, although it requires more skill and more precise
anatomical knowledge, is yet I think to be preferred. With practice it
becomes easy, and I have seen Doctor Chomet, of Bordeaux, complete it in
thirty seconds upon the dead subject. I know none but the circular method
of Cornuau or my own, which surpasses it, and can be substituted for it with
advantage.
OPERATIVE SUROERT. S)lf ^
Art, 8. — Shoulder.
History and Indications. — ^Four patients have been mentioned bj Cheselden,
Carmichael, Dorsej, and Mussey, who had the whole shoulder torn away, and
jei finally recovered. In the army M. Larrey several times took away with
the arm a large part of the scapula or of the clavicle, and success more than
once rewarded his boldness. M. Clot and Mr. Brice removed v^dth the arm a
portion of the scapula, and Mr. Cuming, at Antigua, the whole, and all three
with sftccess. The amputation of the shoulder may become necessary for the^
preservation of the arm. Janson has published one instance, M. Beauchene
operated in another, and Mr. Lucke in a third.
Sometimes this operation is required by a necrosis, a caries, or a commi-
nutive fracture, with a disorganization more or less extensive of the soft parts,
when a simple disarticulation will not completely remove the disease. Some-
times a tumor, i'ormed of abnormal tissues, which comprehends a part of the
arm and extends beyond the joints. Sometimes the tumor or morbid change
of structure occupies only the scapula and the tissues about it, so that the
arm may still be preserved.
Manual. — In the first case the diseased bones are to be exposed as far as
the limits of the disease. The flaps are formed and managed as in ampu-
tation at the joint, and cut in this or that direction, according to the state of
the parts. If it is impossible to avoid the artery, it should be compressed on
the first rib or previously tied. The saw commonly used for dividing small
bones, or chain-saw of Jeffreys, may then be applied, to cut off such portions
of the scapula or clavicle as may require removal. In the other two cases
it would be difficult to lay down any precise general directions. The surgeon
must rely upon his own resources of knowledge and invention.
SECTION II.
Inferior Extremity.
Upon the inferior extremity the amputations are generally more difficult
and more serious than upon the thoracic member. They will be treated here
as they are performed upon the foot, the leg, the thigh, in the continuity, and
in the contiguity.
jirt. l.-^-The Toes.
It is not with the toes as it is witli the fingers. The uses to which the latter
are applied render their preservation more important, and their length admits
of partial amputation. But the former, having an insignificant office to
perform, and possessing but slight extent, maybe taken away all together
without affecting essentially the functions of the foot. For a similar reason
we scarcely ever amputate one or two phalanges of the toes, nor a part of the
metatarsal phalanx, except perhaps, sometimes that of the great toe.
The processes to be followed being exactly similar to those prescribed for
the amputation of the fingers, need not be here repeated. I will only remark.
I,
216
NEW ELEMENTS OF
that the natural cavity which corresponds to the dorsal face of the metatarso-
phalangeal articulation, and the projection which forms the sole of the foot,
render the amputation of the toes severally more difficult than that of the fingers,
and that the oval method is still more advantageous to the appendices of the
foot than to those of the hand. The amputation of two or three, or of all the
toes together, should be performed as on the fingers, in the way recommended
by M. Lisfranc, It is neither more complicated nor more difficult, and there
is the same chance of success. But there are few injuries so severe as to
comprehend all the toes, without affecting at the same time more or less of
the metatarsus ; yet some examples, the result of frost-bite for instance, have
been recorded. I have seen in La Pitie an invalid who had been treated in
this manner nearly forty years before, by La Chapelle. M. Chaumet has
recently published an instance of the same thing.
Art, 2,'^Metatarsus,
The metatarsal bones, like those of the metacarpus, are amputated either in
the continuity, in the contiguity, separately, or collectively. They may also
be extracted, leaving the corresponding toe.
§ 1. In the Continuity,
The amputation of the three middle nietatarsal bones in continuity, is prac -
tised frequently, and always by the same rules, as for the amputation of the
corresponding metacarpal bones. Some surgeons think that it ought to be
preferred to the simple disarticulation of the toes. Mr. Thomas for example,
maintained, in 1814, that it is less difficult and less dangerous, and that the
deformity which results from it is less obvious. This is evidently an error.
To remove a metatarsal bone, it is necessary to divide at two diiferent strokes
the thickness of the soft parts of the sole of the foot, disturb some of the tarso-
metatarsal articulations, and produce a very extensive wound ; while the
amputation of the toe is finished in an instant, and leaves a solution of conti-
nuity, very simple and easy to heal. Thus in the foot as in the hand, and for
the same reason, the metatarsal bone must not be touched, unless it is impos-
sible to remove the disease by amputating only the toe.
First Metatarsal Bone, — The first metatarsal bone is an exception to this
rule. From the time of Le Dran to this day, most surgeons have preferred
dividing it behind its head to separating it at the joint. Dislocating the toe
they say, gives birth to a shocking deformity ; the anterior extremity of the
bones forms a considerable projection, which rubs painfully against the shoe,
and only impedes, instead of aiding the functions of the foot. It is true that
the deformity is less evident after the amputation of the metatarsal bone, than
after the simple removal of the toe. But it is undeniable also that the standing
posture is more difficult to maintain, and less secure in the former cases than
in the latter. In this point of view then, the simple amputation of the great
toe is to be preferred. Other practitioners, and among them M. Gouraud, are
of opinion that it is better to disarticulate the first metatarsal bone than to saw
through it. Le Dran has already pointed out the disadvantages of this method, in
endeavoring to give pre-eminence to the other, which is since generally adopted.
OPERATIVE SURGERY. 217
M. Richerand advised to cut the bone obliquely instead of transversely across.
After the disarticulation, the base of the sore presents a great L, the hori-
zontal branch of which, formed by the cuneiform bone, produces a troublesome
projection on the internal side of the foot. The operation is besides less easy,
and the wound more difficult to unite by the first intention. Amputation in
the continuity leaves no projection on the internal side of the bone, when care
has been taken to carry the saw obliquely from behind forwards. It does not
require the removal of so great a quantity of the parts, nor the disturbance of
any joint. I think it ought to be preferred whenever the disease does not
compel us to carry the instrument up to the tarsus. Three different cases
have convinced me of the justness of these rules.
Manual. — As it is difficult to draw the soft parts inwards from the sole of
the foot, and thrust the bistoury downwards between the bone and the flesh ;
and as it is nearly impossible, especially in doing this, to preserve to the flap
the regularity, breadth, and length desirable ; I prefer making the incision from
without inwards, and tracing its extent and form by dividing the skin from
behind forwards, first on the dorsal and then on the plantar face, to near the
anterior extremity of the first phalanx of the great toe, and then raising this
flap and dissecting it back from its apex to its base. This done, the knife
penetrates the first interosseal space, pressing outwards with its point the
adherent lip of the first incision; grazes the peroneal face of the bone, and in-
clines a little internally to avoid the corresponding lip of the incision on the
sole of the foot, which the operator at the same time draws as much as possible
oiit of its way. The tissues are then divided with a full stroke of the knife,
which is brought out at the commissure of the first two toes. Carried imme-
diately back, it divides all the parts above and below, within and without, that
may yet adhere to the metatarsal bone. A splint of wood or pasteboard, or even
a simple compress thickly folded, placed in the bottom of the second wound,
protects the flesh against the action of the saw. The operator seizes with the
left hand the toe and the articular head which he intends to remove, causes the
foot to be held outwards, applies his thumb nail to the place where the division
is to commence, and then with his right hand armed with a small saw, he cuts
the bone very obliquely from its internal or tibial to its external side, and from
behind forwards. A dorsal or interosseal artery of the metatarsus and one or
two branches of the plantar arteries, sometimes, but not always require ihe
ligature. The flap is brought back on the wound, and exactly applied and
secured by strips of adhesive plaster and a convenient bandage.
B. Fifth Metatarsal Bone, — The last bone of the metatarsus may be ampu-
tated like the rest, in its continuity ; but the projection which it forms behind,
the inutility of what might be preserved, and the facility with which it is
disarticulated, together with the slight deformity which results from this
operation, gives to amputation in the contiguity a general preference. This
amputation is not to be performed like the preceding. The oval method is more
suitable. But if you do not wish to try that, it will be necessary to pass through
the last interosseal space backwards, with the bistoury held vertically from
the commissure of the fourth and fifth toes to the anterior surface of the oscu-
boides ; then to disarticulate the bone, pass from its dorsal to its plantar surface,
disengage its head, and cut a flap from the soft parts of the external side of
the foot, long and wide enough to cover the bntire surface of the wound.
NEW ELEMENTS OF
'•^tii^t' '^ ■•■■ •■ '' '^^
C. Extraction, — The extraction of the middle bones of the metatarsus
would be performed as in the hand, if it could be of any advantage. The
same may be said of thejifth. The preservation of a corresponding toe is of
too little im|)ortance to compensate for the difficulties of sucli an operation.
M. Blandin-, who has lately endeavored to show that it is otlierwise witli the
first toe, says, that after amputation, properly so called, either in the
continuity or in the contiguity, the foot will be continually turning upon its
inner side ; and quoting an instance, which appears to confirm his opinion,
asks whether the amputation of all the metatarsal bones be not preferable to
amputating alone the bone which supports the great toe. Will the simple
extraction, as he believes, prevent these inconveniences ? The transverse
metatarsal ligament preserves some firmness in the position of the great toe,
after the extraction of the bone which naturally supports it. The sole of the
foot maintains its breadth in front, and station and progression suffer very
little from such an operation, which M. Barbier contrived in 1795. Kot
being able to reduce the luxation of the first metatarsal bone, this surgeon
undertook to dislocate it and remove it, preserving the great toe. M. Beaufils,
who published this fact in 1797, said the patient was conxpletely restored at
the end of forty days. It seems to me, however, that there is a mistake upon
this subject; that after the extraction of the first metatarsal bone the
deformity would be greater than after its amputation, and that the toe would
be liable to turn inwards, to change its position, and to interfere with the
motions of the foot. On the other hand, it is not .proper to affirm that the
ordinary amputation is generally followed by the inversion of the foot. It is
an accident indeed that may happen, but more frequently does not. This
proposition is supported by a crowd of facts. I was presented with a new
proof of it in 1 829, at the hospital St. Antoine. I amputated after the common
method and the patient soon recovered. I saw him frequently afterwards ;
he walked continually, and did not even take the trouble to thicken the sole
of his shoe on the inside. I have since seen two more examples at La Piiie,
Before affirming, therefore, that the extraction of the first metatarsal bone
should be preferred to its amputation, it is prudent to wait for further facts.
This QjMiration has been indicated by Hey, of Leeds. ** When the caries is
confined to the metatarsal bone of the great toe," says this practitioner, ♦* it
is customary, after having made a longitudinal and transverse incision, to
remove the diseased portion with the saw. But as it is sometimes difficult to
ascertain exactly the extent of the caries, it is better to separate the whole of
the bone at its junction with the cuneiforme." If the extraction of the meta-
carpal bones has received general approbation, it is because it preserves the
fingers, and affects but little the form and valuable uses of the hand, while
neither the same advantages nor the same results are to be expected from a
similar operation on the foot. The method of operating would be the same,
unless some complication should force us to imitate M. Barbier.
D. Jill the Metatarsal Bones. — Though it was usual with surgeons up to the
time of Chopart, to amputate the leg for diseases which did not involve the
whole foot, they yet sometimes confined themselves to a partial amputation of
the foot, which it is now the rule to amputate as near the toes as possible.
According to F. de Hilden, de Verdue, &c., the partial amputation of the
metatarsus could not have been unknown to the ancients, who performed it
OPERATIVE SURGERY. fil9
■with the chisel and mallet, or else with the machine of Botal, and no doubt
only in the continuity. Sharp has proposed that a little saw should be used,
and asserts that he has seen it once executed with success. Hey proposed it
anew towards the end of the last century, and alleged that in the case of a
young woman, he had removed the first four toes with a gi-eat part of the
corresponding metatarsal bones, but complained of the length of time it took
the wound to heal. M. Lisfranc also has advised that the operation should
be performed particularly on young persons, because in infanrcy the bistoury
may take the place of the saw. M. Raoul in 1S03, and Mr. Thomas in 1814,
again brought forwards this proposition in their theses, supporting it, I think,
on very good reasons. M. Pezerat has once practised it with success. I do
not see indeed why the transverse section of the metatarsus should not be
performed, rather than its dislocation, when the disease permits it.
Manual. — A small knife thj'ust through from one side to the other, grazing
the plantar face of the bones, cuts a flap of the proper length from the soft
parts of the sole. By a semicircular incision inclined a little forward, the
skin on the dorsal face is next divided, and tlien the tendons, some lines in
advance of the point ^here the saw is to be applied. The flesh being drawn
back by an assistant, the surgeon successively denudes the bones with the
bistoury at the base of the flap, so as to render easier the simultaneous or
successive division from on<i side to the other, or from the back of the foot to
its sole, M. Pezerat's process is to make three flaps, ^ dorsal, a plantar, and
an internal one. This Should never be followed, unless the pathological state
renders the former process inapplicable.
In Contiguity.
Historical, — ^In cases where the state of the foot does not permit the sawing of
the metatarsal bones, or the surgeon does not wish to resort to tliis operation,
it is possible to dislocate them and preserve the tarsus, with the action of cer-
tain very important muscles. Garengeot says, *• this amputation is very
troublesome, since it has to do with a number of junctions which are not in
the same line. To conduct the bistoury between the metatarsal bones, &c.,
cut the ligaments which unite them,'and save as much of the skin as possible,
is all the direction that can be given," Le Blanc is still more laconic. *' One
can, in certain cases, amputate a part of the foot, saw the metatarsal bones,
and even separate them at their articulation, as several practitioners have
alleged." It is the same with Brasdor, According to Mr. S. Cooper, it was
practised in England by Turner, in 1787. Percy performed the same ope-
ration with a great deal of trouble, on a monk of Elairvaux, in 1789. It is
described in the thesis of M. C. Petit (1802). M. Berchu attempted it with
success, in 1814. M, J. B. J, A. Blandin, who frequently practised it in the
army, gives the following directions : ** Carrying the knife behind," he says,
*' I cut the skin and the tendons on the back of the foot, holding the edge of
the knife backwards, and making it glide on the body of the bones back to the
place of their a.'ticulation, so as to preserve a small dorsal flap ; then I divide
all the ligaments ; afterwards, with the point of the instrument conducted
just below tlie tarsus through the articulation, I cut the connexions and am-
putate the whole at a single stroke by a transverse section, preserving as
380 NEW ELEMENTS OF
above a little of the sole of the foot, to form a second flap." The directions
in M. Plantade's thesis (1 805) were very nearly the same. But it was neces-
sary that M. Villerme, and more particularly M. Li^franc, should make it the
subject of an especial work, which they presented to the institute in 1815, to
draw to the disarticulation of the metatarsal bones all the attention it deserves.
In merely saying the amputation is diflicult, we only deter from its execution.
There was lacking an explication of the difficulties and of the means of obvi-
ating them, and this deficiency has been happily supplied by M. Lisfranc.
Anatomical Remarks. — The three cuneiform bones united, present in front
^ a kind of mortise moderately open, which is exactly filled by the posterior
extremity of the second metatarsal bone. The interior wall of this cavity,
formed by the first cuneiform, is about four lines in length and an inch high,
while the external wall which is formed by the last, is only two lines in extent
from before backwards. The articulation of the first metatarsal bone, which
is consequently two or three lines before that of the third, is less narrow than
any of the others ; its surfaces are so disposed, that that of the tarsus are a
little convex to suit the slight concavity of the other, and that they present a
" doubly oblique plane, first outwards, in the direction of a line which would
fall near the middle of the metatarsal bone of the little toe, and secondly,
downwards and forwards. The articulation of the middle metatarsal bone,
placed transversely like that of the second, is two lines in front of the bottom
of the mortise above described.
The interline of the fifth is oblique inwards, in a line which would fall upon
the middle of the first metatarsal bone, whilst the fourth is nearly transverse
at its external part, but inclines forwards like the preceding from where it
tends to join the third, one or two lines behind which it is commonly found.
As the second metatarsal bone is cased between the bones of the tarsus, so it
is seldom that the third cuneiform is not wedged likewise in a kind of mortise
one or two lines deep, which is formed by the third metatarsal bone in front,
joined on either side with the second and the fourth. If the first cavity did
not exist, the second would also be wanting. Indeed, if the third cuneiform
bone lay in the same plane as the second (which scarcely projects in front of
the cuboidal facet of the fourth metatarsal bone), the articulation throughout
would be perfectly regular. In fact, this disposition is met with sometimes,
and then the amputation is generally very easy. But frequently too, this bone
projects so far as to be nearly on a line with the first cuneo-metatarsal articu-
lation. In this case, the two mortises are equally difficult to disunite. Other
anomalies frequently occur. I have seen, for example, the anterior internal
face of the cuboides, pass half a line or even a whole line beyond the meta-
tarsal face of the third cuneiform bone.
On another subject, the two last metatarsal bones united, presented a ridge
of which the crest placed vertically was buried three lines deep in the front
part of the cuboides, and this in both feet of the same cadaver. At another
time, I found the dorsal edge of the extremity of the third metatarsal bone
inclined obliquely backwards to the extent of a line and a half, upon the cor-
responding cuneiform bone. Messrs. Lisfranc and Zeigler have remarked
that the tubercle of the fifth metatarsal bone is sometimes prolonged to a line
with calcanear articulation, and I have noticed a tubercle in the form of exos-
. tosis on the dorsal face of the second cuneo-metatarsal articulation, on per-
OPERATIVE SURGERY. 221
8ons who are in the habit of wearing tight boots. Lastly, many of these joints
may have suffered anchylosis.
There is no necessity for a description of the dorsal ligaments that connect
the tarsus with the metatarsus, either an tero -posterior or transverse, as they
are mere fibrous bands fixed under the tendons, without penetrating between
the articular surfaces. It is not exactly the same with the plantar surface.
There almost all the bones terminate in a kind of point or flattened crest,
which by permitting them to incline towards each other, determines the trans-
verse concavity of the foot, and leave between them small triangular spaces,
filled with fibrous masses. One of these masses, that which unites the exter-
nal face of the anterior prominence of the first cuneiform to the internal sur-
face of the second metatarsal bone, requires great attention. Besides being
very thick and strong, and formed of fibres oblique in the direction of the first
tarso-metatarsal articulation, it is especially remarkable from its vertical ex-
tent bounded by that of the articulation itself. There is nothing important
to notice respecting the others.
The tarso-metatarsal articulation, viewed as a whole, presents a line slightly
convex forwards, the extremities of which nearly correspond to the middle of
the space between the malleolus and the base of the toes. On the outside it
is indicated by the posterior extremity of the tubercle, which the last meta-
tarsal bone presents under the skin. It is also very easily discovered in the
inside, by observing that under the tegument and near the sole of the foot,
the first cuneiform and the first metatarsal bone have each a prominence,
leaving a depression between them which marks the beginning of the articu-
lation. A line transversely drawn from its external extremity to the internal
side of the tarsus, falls a little in front of the scaphoides, about three quarters
of an inch from the internal tarso-metatarsal articulation. Consequently,
there can be very little difficulty in knowing its situation and direction before
beginning the operation. As the tendon of the peroneus longus, in passing to
its attachment to the inferior or plantar tubercle of the posterior extremity of
the first metatarsal bone, generally contracts some adhesions with the third
cuneiform bone, the simple disarticulation of the metatarsal bones does not
necessarily destroy the action of that muscle. It is the same with the anterior
peronei muscles which are inserted, at least in part, into the dorsal face of
the cuboides ; and with the anterior and posterior tibial muscles, the attach-
ment of which is not severed by the operation.
Manual, — The disarticulation of the metatarsal bones is certainly the most
difficult that can be met with. The usual directions are to make use of the
bistoury and saw at the same time.
A. Process of Hey. — In 1799, Mr. Hey performed the following operation
on a young girl of eighteen : — He made a transverse incision about half an
inch to the front of the articulations, and another on each side, from the cor-
responding extremity of the first to the roots of the first and fifth toe. He
then detached all the soft parts of the sole of the foot, and turned them back,
to form a flap. After having disarticulated the last four metatarsal bones, he
determined to remove the projection of the first cuneiform with the saw : the
patient was perfectly restored. This process, may no doubt, be imitated ; but
it is evident that the lateral incisions, and the precaution of forming a plantar
flap before disarticulating the bones, renders the operation longer and more
222 NEW ELEMENTS OF
difficult. In saying that the last four metatarsal bones are found on the same
line, Hej seems to me to mean that the posterior facet of one projects but
little beyond that of the other, and not, as he has been made to say, that they
form a complete transverse line. As to the section of the first cuneiform, I
do not think it merits the reproach that is of late attached to it.. Beclard,
M. Scoutetten, and even M. Lisfranc, have practiced it without any disadvan-
tageous result.
B. Process of M. J. Cloquet. — After the soft parts of the dorsal, face of the
foot have been divided, M. J. Cloquet prefers sawing the bones transversely
instead of stopping to disarticulate them. I do not see why it would be more
dangerous than the simple disarticulation. A priori it even seems that it would
be less frequently followed by serious accidents. The tearing, rather than
cutting of the ligamentous or fibrous tissues, which some persons dread, seems
to threaten less inconvenience than the wrenching which is inflicted upon the
articulation of the tarsus, in separating from it the metatarsus with the knife.
It is yet a question whether the surface of the sawn bones is as well adapted
as the cartilaginous surface, for the immediate union of the wound. This
advice appears to have beeix given by M. J. Cloquet only for the use of those
who have not been able to become sufficiently familiar with the tarso -metatar-
sal disarticulation^
C^ Process of M. Lisfrant.- — I do not here notice the process of M. Vil-
lerme, since he was himself the first to speak in decided preference of that of
M. Lisfranc.
First Stage. — During the whole of this operation a narrow firm knife is>
used. A good bistoury nevertheless may serve until the plantar flap is to be
cut. If the surgeon is ambidexter, the rule is to begin always with the exter-
nal side of the foot, consequently carrying the knife with the right hand for
the right member, and with the left hand for the left; otherwise, he commences
in this last case on the internal side of the metatarsus. The patient is placed
on a table, or on a bed properly pillowed. An assistant, holding the lower part
of the leg, compresses the posterior tibial artery behind the internal malleolus
and the anterior tibial on the instep, at the same time that he draws back the
skin from this latter part. The surgeon ascertains first, by sliding his fore-
finger backwards along tlie dorsal and external side of the fifth metatarsal
bone and of the internal and plantar face of the first, the two extremities of
the articular line ; he fixes the thumb and index finger of one hand on the
tubercle of each of these bones, embracing the end of the foot underneath,
according to some, or on its dorsal face according to others, and as I prefer it
myself, in order to act with more ease on all the metatarsal bones. With the
other hand armed with a knife he makes a semicircular incision convex for-
wards, the extremities of which should fall upon the two tubercles indicated
by the fingers, and which divides or should divide only the skin and subjacent
cellular membrane. The teguments being drawn back the instrument is reap-
plied in the first incision, in order to divide the extensor tendons and other soft
parts which may remain over the bones at the edge of the retracted skin, and
so that this second incision may correspond to the articular line. It is import-
ant in arriving at the side of the foot, to be careful not to descend too low
towards its plantar surface, for fear that in ending the operation the base of
the flap should be curtailed of its necessary breadth.
OPERATIVE SURGERY. 223
Second Stage, — If the cuboido -metatarsal articulation have not been opened
with the stroke which divided the tendons, it may be penetrated by carrying
the point of the knife behind the tubercle of the fifth metatarsal bone, in the
direction of a line which would fall obliquely in front, first on the head, then
on the middle part, then on the posterior extremity of the first metatarsal
bone, being placed almost transversely, on arriving at the fourth, inclined
again in front on entering the articulation of the third, which is separated by
carrying the knife transversely. The second metatarsal bone generally pre-
vents the knife from penetrating any further in that direction. It is then
withdrawn, and applied with the point upwards to the inside of the foot, so as
to pass obliquely inwards and forwards through the articulation of the first
metatarsal bone. The surgeon then places the knife perpendicularly, with
the point downwards and the edge turned backwards, or on the internal side
of the before -mentioned mortise ; he thrusts it towards the sole of the foot at
the angle made by the caseous faces ; then pressing on the handle, so as to
sway it back and forth, divides the thick ligament, called by M. Lisfranc the
key of the articulation, draws it out again to seek the posterior articulation of
the second metatarsal bone. For this purpose he places the point horizon-
tally across the superficial face of this, bone, and as the articulation is never
more than three lines behind, it is easy to. open into it by cutting at every half
line from the middle articulation, which is already exposed, until it is found.
After this has been done, all the osseous surfaces separate, and the point of
the knife sliding among them easily divides the rest of the ligaments.
Third Part. — Nothing more is to be done, except to form a flap by grazing
the plantar face of the bones as far as the metatar so -phalangeal articulations.
This flap should not end square but obliquely, and should be slightly rounded
at its digital extremity and not transverse, in order to correspond to the semi-
circular curve of the dorsal side of the stump. To avoid leaving the internal
side of the flap thinner than the external, care must be taken in cutting it to
keep the handle of the instrument more elevated than the point ; and in order
that the phalangeal head of the metatarsal bones, especially the first, should
not arrest the blade of the instrument, it is important to incline the edge de-
cidedly and in good time towards the skin»
i)re.55?Vio».— ^The arteries divided are the plantar, internal and external, the
anterior tibial, and some other secondary branches of littie importance. The
principal flap when applied against the articular surface, ought to cover it
exactly, and to fit with its edge the small flap preserved on the dorsum of the
foot. If in this last direction the teguments had been divided to a level with the
articulations, the bones of the tarsus would be found naked immediately after-
wards^ As the tendons retract less than the skin, if they were to be sepa-
rated at the same stroke, their ends would remain fr^e between the sides of
the wound and obstruct its reunion. It would be better in this ease to cut
them again with the scissors. In order to maintain more firmly the coaptation
of tlie parts, the adhesive straps should be stretched from the posterior internal
and inferior surface of the heel, to the wound, then along the back of the foot,
around the lower part of the leg, or at least as far as the parts about the mal-
leolus. The patient should be placed on his bed, so that the leg and foot on
which the operation has been performed may be turned on their external side^
and as completely relaxed as possible. Here, more particularly thaa after
224
any other amputation of the extremities, regular and uniform compression
applied from the limits of the third part of the leg down to the wound, will be
the best means to prevent the development of inflammation, synovial, venous,
or of any other kind.
D. Process of M. Maingault. — The method of M.Maingault in this case is
exactly analogous to that which he proposed for the disarticulation of the meta-
carpus. Though practicable, it appears to me to be in all respects less advan-
tageous, and more difficult than the preceding, and consequently to be useful
only in cases where that is impracticable.
Art, 3. — Amputation of a part of the Tarsus,
Tlie three cuneiform bones, the cuboides, the scaphoides, are generally
removed at the same time. Nevertheless, if the cuboides alone is affected,
with the two metatarsal bones which it supports, we may, like Hey, remove
only the external third of the foot. Unless there is an absolute necessity, the
whole of the metatarsus should not be amputated in the articulation. The
operation should be limited to the disarticulation of the diseased bones. The
fourth and fifth metatarsal bones, for example, may be amputated by them-
selves with as much facility as the corresponding metacarpal bones ; it is the
same with the first two. Some observations published by M. Miarault, in 1824,
and collected during the attendance of Beclard, at La PitiCy showing the just-
ness of these assertions, have fully confirmed what experiments made on the
dead subject had already rendered probable.
The amputation between the os-calcis and the astragalus on one part, and
the scaphoides and the cuboides on the other, is, like that of the metatarsus, an
operation of which no trace is found among the ancients; and which would
have belonged entirely to France if F. de Hilden had not pointed it out with
sufficient clearness, since M. Chopart was the first that positively described
it ; and the operation has since been improved only in France.
Anatomical Remarks. — The articulation traversed by Chopart, is much less
complicated and less difficult to disunite than the preceding. The four
osseous surfaces of which it consists possess some mobility, and are far from
being so closely connected as those of the tar so -metatarsal articulation. The
rounded head of the astragalus is retained in the cavity of the scaphoides only
by some loose fibre ->cellular bands. Outside, and on the dorsal face, it has
the same kind of attat^hments to the calcaneum and the cuboides. The strongest
and most important ligament of this articulation is that which goes deeply
from the os-calcis to the peroneal extremity of the scaphoides, and which may
also be called the key of the articulation. The articular line is divided here
into two very distinct portions. Its internal half represents a half-moon, re-
gularly convex forwards. Its external or calcanear half presents, on the
contrary, a plane, oblique outwards and forwards, in such a manner that in
connexion with the other it forms quite a deep sinus, that seems continuous
with the dorsal excavation of the os-calcis, and into which it is easy to stray
at the time of the operation, if its disposition is not exactly remembered. Like
that of the metatarsus, the articulation of the bones of the tarsus among
themselves is very concave and unequal on its plantar aspect, where the sca-
phoides and the cuboides present a projection which ought not to be forgotten
OPERATIVE SURGERY. 2£5
in the separation of the soft parts from those bones. Its internal extremity is
marked by a slight depression, which is bounded behind by the tuberosity of
the calcaneum, and in front by the corresponding tubercle of the scaphoides,
which last projection prevents any groping for the articulation of the astra-
galus and naviculare. On the dorsum of the foot the articulation in question
is indicated by a slightly depressed line, which may be felt with the finger in
front of the head of the astragalus. The tendon of the tibialis posticus is
attached to the internal and inferior tubercle of the scaphoides, and the tibialis
anticus to the first cuneiform bone.
As the tendon of the peroneus longus passes under the cuboides, the re-
moval of the last five bones of the tarsus necessarily destroys the attachments
of these three muscles, while the disarticulation of the metatarsus permits us
to preserve them. Some anomalies may change the value of these data.
Sometimes the tuberosity of the scaphoides is scarcely appreciable. In other
cases, there may be in the passage of the tendon of the tibialis posticus a sesa-
moid bone, which will in a great measure fill up the articular depression. M.
Prichon has been remarked that the calcaneo-scaphoid ligament, or the articular
key, mentioned above, is sometimes transformed into a cartilaginous epiphyses,
and afterwards become completely osseous, even on very young persons. He
has met this frequently, and subjected one example of it to the inspection of
the professors of the faculty in defending his thesis.
We may conceive the difficulties which such an anomaly throws in the way
of the operator. It was this, no doubt, that produced the anchylosis which Sir
A. Cooper was obliged to break in order to finish a partial amputation of the
foot; and that mentioned by M. Ficher, and which would have yielded only
to the saw, if it had been necessary to amputate during life. M. Plichon re-
marked, and very justly, that the head of the astragalus projects beyond the
plane of the anterior face of the calcaneum, more in some cases than in others ;
and that the calcaneo-cuboidal articulation is then less oblique forwards.
Operation. — The modes of disarticulating the scaphoides and the cuboides,
can vary only in the most unimportant details. Chopart, who was not guided
by the present anatomical data, thought it very difficult. It is true, that in
1779, a celebrated surgeon of Paris was nearly three quarters of an hour in
completing it, though he had before his eyes at the time the foot of an arti-
culated skeleton ; but since M. Richerand and Bichat showed that the pro-
jection of the internal extremity of the scaphoides may be felt under the
skin, the difficulties which formerly accompanied the operation have been
removed, and it is now one of the easiest in surgery.
1st. Process of Chopart. — The position of the limb and that of the surgeon
should be the same as for the preceding disarticulation. A transverse incision
is first made two inches in front of the malleolus. At the extremities of this
incision two smaller ones are made ; the trapezoid or quadrilateral flap which
results is dissected, and turned back towards the leg. The operator opens
the articulation from the internal side of the foot towards the external, and
in passing through it divides the calcaneo-scaphoidean ligament; arrives at
the plantar face of the scaphoides and cuboides, and finishes by cutting the
flap as far as the heads of the metatarsal bones.
2d. Process of M. Richerand. — Messrs. Walther and Graefe, still describe
the partial amputation of the foot in the same manner as Chopart, although
29
NEW ELEMENTS OF .
the modification proposed by Bichat and M. Richerand had been adopted for
some time in France ; that is, instead of forming the dorsal flap by three inci-
sions, to make one semicircular incision convex forwards, which is placed
only a few lines in front of the articulation. Klein and Lisfranc have pro-
posed to draw it directly over the articulation.
3d. Process of M. Maingault. — M. Maingault proceeds from the plantar
to the dorsal face, in disarticulating the bones of the tarsus from one another,
the same as in removing the metatarsus and metacarpus, and thinks that this
process should be adopted, at least as an exceptionary method. On that
point, I am entirely of his opinion.
Remarks. — It is superfluous to discuss the relative importance of these
varieties of the general operations. All may find their application in practice,
if, for example, there are soft parts only on the dorsal face susceptible of being
preserved ; it is evident that the flap should be taken from those parts entirely,
or from the inferior part, if the teguments on the back of the foot are disor-
ganized up to the leg. If there is not enough of the healthy tissues, either
above or below, singly to form a flap capable of covering the wound, I do
not see why two of equal extent should not be cut. But if the sole of the
foot be not too far disorganized, Bichat's plan is certainly the best and most
rational.
4th. Process adopted by the Author. — 'First Stage.-^~Wh\\e the assistant
compresses the arteries and draws back the integuments, the surgeon
embraces with one hand the back of the foot, in such a manner that his fore-
finger presses upon the tubercle of the scaphoides, and with a little knife in
the other hand makes an incision slightly convex in front, the extremities of
which correspond to the extremities of the articular line, and which he carries
from the internal to the external side of the foot, for both feet if he is ambi-
dexter ; otherwise, from the external to the internal side for the left foot.
After having caused the tissues to be withdrawn, and carried the instrument
back to the bottom of the wound, he divides in the same direction, near the
retracted skin, the tendons and the other layers which still cover the osseous
surfaces, and generally opens the articulation by this second stroke :
Second Stage. — If not, then after again assuring himself of the situation of
the scaphoidean tubercle, he cuts from within outwards all the ligaments on
the dorsal face which unite the scaphoides to the astragalus, without endea-
voring to penetrate the articulation, as the head of this last bone would prevent
this. He describes in this way a semicircle, taking care not to prolong the
external branch too far behind, but on the contrary, in order to detach the
cuboides ; to incline the edge of the knife first transversely, then a little for-
wards ; and, as soon as the surfaces are sufliciently separated, to divide the
thick fibrous mass which unites the calcaneum to the scaphoides, and finally
to arrive at the plantar side of the articulation.
Third Stage. — The operator then directs the edge of the knife forwards
along the inferior face of the tarsus, and cuts the plantar flap ; lowering his
wrist for the left foot or raising it for the'right, so that the flap may not be
thinner on the inner edge than on the outer, and prolongs it more on the
internal side than on the external, because the astragalus ascends towards
the leg higher than the os-calcis. As the vertical thickness of the osseous
surfaces^ here exposed is much greater than after the disarticulation of the
OPERATIVE SURGERY. 227
metatarsus, the flap ought to be extended in front as fer as in that operation,
although this is commenced nearly two inches farther back.
Dressing,^— To tie the arteries as fast as they are opened, as Chopart has
advised, is a useless precaution. After the operation, the anterior tibial and*
the two plantars are all that require attention. The dorsal integuments are?
also brought forwards.
The plantar flap is applied against the cartilaginous surfaces, and retained
there by long strips of diachylon, and by a rolled bandage accurately applied.
*^rt. 4. — Comparison of the two partial imputations of the Foot.
Since skillful surgeons have shown that it is possible to disarticulate the
metatarsus as well a&the anterior range of the tarsus, it has been asked which
of these two operations should be preferred. This question should not have
been raised ; they are not intended to supersede one another. Each of thenv
has its special applications ; and if there be any diff*erence between them as io.^
difficulty, pain, and danger, it is not sufficient to countervail the rule before^
laid down — to amputate as near the toes as possible.
»^rt. 5. — Extraction of some of the Bones of the Tarsus. ^^p
Many surgeons extract the astra2:alus, and thus preserve the use of the foot
and leg. Cases are related by Dupuytren, Despeaux, Fallot, Dassit, Charley^f^
Lockeman, and Modesti.* But it is only in case of luxation, with laceration
of the soft parts, that such an operation is necessary. As the same condition
of the parts is seldom found in two different cases, it is impossible to give
fixed rules for operating. We must be governed by existing circumstances :
observing at all times to divide as few tendons as possible, and to operate-
before general reaction manifests itself, and as soon as possible after the acci-
dent. The cuboid, scaphoid, and great cuneiform bones, may each be removed
when they cannot be preserved, as in a case of luxation complicated with
caries or necrosis. Here, too, the surgeon must also be governed by the cir-
cumstances of each case.
v^r/. 6. — Extraction of the foot.
Besides the rule, in other respects so just, that we should only remove the
least possible of parts, surgeons have asked if the disarticulation of the foot
ought not to be preferred when it may prevent the amputation of the leg ? if
after this disarticulation it will not be possible for the patient to walk with a
peculiar shoe, a sort of half-boot, which will conceal his deformity ? It has been
performed once with success by Sedillier. He, Laval, and Brasdor, affirm
that the cicatrix, which was quickly formed, neyei? reopened during the twelve
years that the patient subsequently lived. Hippocrates, F.de Hilden, and
Scultetus seem also to have thought of it,though very vaguely. Since then others
have again proposed it,withoutsucceedinghowever in introducing it into prac-
tice. The projection which the tibial malleolus presents, would prevent the
cicatrix according to some, from supporting the weight of the body after the cure*
• In the case of the patient treated by Dr. A. H. Stevens, in 1826, the tibio-tarsal
articulation remained movable, and the foot but slightly disfigtired.
2S8 NEW ELEMENTS OF
m
The want of soft parts and the numerous tendons that surround the articu-
lation, not permitting us to expect immediate union, must beget strong fear of
serious consequences. But are not the most of the dangers and difficulties
imaginary ? It is certain, as Brasdor has already observed, that the mal-
leolar points soon become blunted, and the whole extremity of the member
rounded ; and that it is possible to save skin enough to cover a great part of
the wound. Some theoretic objections which have been advanced are not a
sufficient basis for a definite opinion in such a case, and I think that if favor-
able circumstances should present themselves, it would be proper to make
some trials. M. Confrie long since observed an old soldier at Saint Cathe-
rine, who underwent it in the Russian campaign, and who walks very well
with a half-boot.
Operation, — The operation itself presents no difficulty. Two semilunar
incisions, one passing over the instep, the other over the heel, at twelve or
fifteen lines before and behind the articulation, and uniting so as to form
another semilunar one on either side at about an inch below each malleolas,
constitute the first step. After dissecting up the skin, the tendons, muscles,
and ligaments are to be divided as near as possible to the articulation. Then
the astragalus can be separated without difficulty, and removed with the rest
of the foot. The haemostatic means having been applied, I would recom-
mend the lips of the wound to be brought together anteriorly and posteriorly
so tliat its angles should cover the malleolar points. It is for this that I pro-
pose to divide the integuments at some distance from tJie ancles and the articu-
lation, and not quite upon them, as recommended by Brasdor, Sabatier, and
others. By placing the flaps laterally, as Rossi advises, the malleoli will
render their coaptation altogether impracticable; and it would be ridiculous
at this day to attempt to hold them, by passing a double ligature across the
articulation, as this author is said once to have done with success.
Art. 7. — •imputation of the Leg,
This amputation is more rarely practised than formerly ; but is even at the
present time often rendered indispensable, by diseases of the tibio-tarsal
articulation, complicated fractures, wounds from fire-arms, gangi-ene, &c.
Place of Operating — of Election. — The rule which requires that an am-
putation should be made as far as possible from the trunk, has scarcely ever
been applied in this case. The place of election for dividing the bone, even
when the disease does not reach above the inferior articulation, is at two or
three fingers' breadth from the tuberosity of the tibia. The tendinous
expansion of the sartorius, the gracilis, and semitendinosus, will be preserved.
The stump, which will retain its power of flexion and extension, will be
sufficiently long to allow the knee to be fixed firmly and easily upon the
artificial leg. It is easy to save enough of the soft parts to cover the wound.
By operating too near the malleolus nothing is met with but skin ; the cicatrix
forms slowly, remains tender, and is easily torn. After the cure, the stump
projecting too far backward and constantly exposed to injury from surrounding
bodies, must become more embarrassing than useful ; so much so, that some
subjects operated upon in this way have of their own accord desired another
operation; of which Sabatier has given some examples, and on which Pare
*
OPERATIVE SURGERY. 229
has made some remarks. Higher up the saw will divide the tibia in its
thickest and most spongy part, and the fibrous expansion that propagates the
action of certain muscles of the thigh upon the stump : such at least are the
motives which have been invoked for a long time to support a precept which
is now questioned. However, Soligen, who lived towards the end of the
sixteenth century, strongly opposed this doctrine. According to him we
should amputate the leg, like the arm, as low down as possible. With the aid
of a shoe, supported by two thin and polished plates of steel, fixed upon the
side of the leg by means of engrenures skillfully arranged, the patient could
walk with almost as much facility as with the natural foot. Many foreign
surgeons agreed with him, and Dionis was not far from adopting his opinions.
There had been, however, nothing further said about this when Ravaton,
White, and Bromfield, towards the middle of the last century, made as they
thought the discovery of it. Like Solingen, these authors extolled the em-
ployment of machines, and among the rest that of Wilson, which permits the
flexion and extension of the leg, and of walking in fact as with a natural
member. Ravaton 's boot, fixed by means of straps, had a vacuity correspond-
ing to the cicatrix, in order to preserve it from compression. But Sabatier
properly objects to this, that the weight of the body forcing the integuments
of the stump upwards, must strain the cicatrix so much that it will be torn,
M. Larry is of the same opinion. Vacca, Brunninghausen, and Souleraj.
have nevertheless ventured to restore it to use at the present time : the am-"*
putadon of the leg at its inferior part is a much less serious matter, it must
be acknowledged, than at what is called the place of election, since there is
less of the soft parts met with there. The integuments that are preserved are
sufficient to produce union even by the first intention. It cannot be thought
impossible to construct a machine so perfect as to resemble the abstracted
member, and allow of its use with little evident deformity. Solingen, White,
Ravaton, Bell, Bromfield, and many German surgeons, report cases to prove
the contrary. But if some patients suffer from this plan, it does not follow
that it should be rejected with all others : success in such cases must depend
on many circumstances which have not, I think, been properly estimated.
It may be that the cicatrix shall be more or less solid, or placed at the centre
or towards the circumference of the stump. Allowing that we have not yet
given the boot all the qualities desirable, it does not follow that this is ulti-
mately beyond the reach of human invention. The two subjects thus ope-
rated upon that have been presented to my observation, could travel with a
boot so imperfect, that I can hardly believe in the absolute necessity of making
the knee the point of support for the artificial member. Hence I conclude
that with subjects who are not obliged to make long and fatiguing efforts at
walking, or who are desirous of maintaining the appearance of the natural
form of the part, Solingen's method may sometimes be adopted. If I am not
deceived, there would in that case be some advantage in dividing the integu-
ments in such a manner that the cicatrix would form behind, and not at the
centre of the stump.
Some persons have placed the point of election either higher or lower than
I have done. Hey, for example, places it in the middle of the member. M.
Garigue, on the contrary, with de la Motte, and Bromfield, advises us to
amputate much nearer the articulation, and even above the tuberosity of the
2S0 NEW ELEMENTS OF
tibia. M. Larry strongly counsels this course, and M.. Guthrie also formally
approves of it.
The Place of Necessity. — Yet the point where these different surgeons
amputate, should be considered as a place of necessity rather than of elec-
tion. On this subject I perfectly agree with them, and would always prefer
the amputation of the leg, were it but at an inch below the articulation, to
the amputation of the thigh, if it be not allowed to amputate in the joint. I
even believe, that as a general rule it would be better to cut the bone imme-
diately below the tuberosity of the tibia, than in the place commonly preferred.
The section of the tendons and ligaments does not prevent these and their
muscles from maintaining their action upon the superior extremity of the
leg. Here there is no interosseal space. The popliteal is the only artery to
be secured ; at least the peroneal and posterior tibial are tlie only others that
can require attention. The head of the fibula maybe removed. Then the
amputation of the leg resembles that of any single-boned member of the
skeleton. The spongy nature of the tibia, so far from being an inconve-
nience, on the contrary offers the advantage of an immediate union, and an
easy and prompt development of cellular granulations. But it must be
confessed that the integuments alone exist on the anterior semi -circumferences
of the member, whilst below the muscles come to our assistance ; but as it is
the integuments that ultimately close the wound, I cannot see any great dis-
advantage to result from this circumstance. So that if the spongy substance
of the tibia, in contact with the pus, does not expose the subject to phlebitis
and the reabsorption of morbific matters ; if in operating above the head of
the fibula there be no risk of opening the synovial sac of t!he knee (which
sometimes prolongs itself so far, according to Berard, who has communicated
two examples of it, and as I have myself once seen), I would approv-e without
reserve of the doctrine of Garrigue and Larrey. When the disease reaches
Tery near the knee, to preserve the inferior attachment of the rotular ligament,
and to l-eave untouched the mucous bursae situated behind, M. Larrey recom-
mends that the saw should be applied more or less obliquely from before
upward, and backwards. We may thus remove the whole of the fibula, whilst
Ave leave a small portion of the tibia, which will serve equally well for the point
'of support for the artificial limb; but in such cases it seems better to amputate
in the joint.
Jinatomical Remarks. — After the preceding details, there is no necessity
here for a prolonged description of the leg. The tibia, much thicker than the
fibula, and much more elevated, causes the greatest thickness of the member to
be from within outward, and from before backward, instead of transverse. Its
internal face is -entirely uncovered by muscles, and cannot be covered either
circularly or with a flap, except by the integuments. Its sharp edge, a kind
of crust which presents anteriorly, gives to this portion of its section a point
commonly very sharp and capable ofproforating the skin, if proper attention
be not paid to it. The muscles of the leg that fill the external interosseal
fossa, adhering through almost their whole extent to this excavation, are
incapable of retracting more than a few lines after being divided. It is the
same with the lateral j)eroneals that form the deep muscular layer of the
limb, and the flexors of the toes which fill the posterior interosseal fossa, whilst
the gastrocnemius and soleus can retract very considerably when we operate
OPERATIVE SUROERr. 231
very low. The anterior tibial artery bending at a right angfe as soon as it
gets upon the interosseal ligament, soon joins the nerve of the same name.
The posterior and anterior tibial arteries which separate either higher or lower
from the popliteal, are rarely wanting : the first is found behind the external
border of the tibia, on the posterior face of the common flexor and the tibialis
posticus) the second behind the fibula, in the thickness of the fibres of the
long flexor of the great toe. And the nerve is almost constantly placed upon
the fibular side of the tibial artery.
Manual.
The leg may be amputated by either the circular or flap method .^
A. Circular Method. — Position of the Patient, of the Assistants ^ and of the
Operator. — The patient should be placed upon a bed or a table, and properly
supported. To guard against hemorrhage, compression must be made upon
the femoral artery over the os pubis, by the thumb of an assistant, a handled
pad, or some other instrument; or on a level with the lesser trochanter
against the internal face of the femur, by means of the fingers sunk into the
groove formed by the vastus internus before and the abductors behind ; or, in
fine, by the tourniquet or garot. When the assistants are not sufficiently
numerous, or cannot be entirely depended upon, the garot or tourniquet is
to be preferred* These instruments may be employed with the greater
security, inasmuch as being applied upon the thigh they in no wise incommode
the operator during the amputation. The operator places himself commonly
on the inside ; this is a long-established general rule ; the reason assigned
for which is, that it is more easy to terminate the division of the fibula before
having entirely got through the tibia, than if the operator were on the out-
side. Le Dran had remarked, however, that the surgeon could, if it were
necessary, disregard this rule without danger and even perhaps with advan-
tage. M. Grjefe and S. Cooper, maintain that it is as well that the sur-
geon should always place himself on the outside ; but that it is useless to
keep this latter position for the amputation of the right limb. In a word,
though on the left, the corresponding hand turned towards the head of the
member can draw up the integuments as they are divided by the right, for the
other limb this is not possible, when the operator follows the general rule.
Consequently the precept which it is proper to substitute for the ancient, and
to which I have for a long time conformed, is this: the operator shall place
himself in such a manner that the left hand can always embi'ace the limb towards
the knee; at least if he be not ambidexter. But if he be, it would be better
to place himself on the inside for either, than on the outside for both. It
would be idle to place himself on the outside for the division of the soft parts,
and then inside for the bone, as some German and English surgeons have
recommended. It would be still more improper to leave the sound limb
between the operator and the limb that he wishes to amputate, under the pre-
text of never placing himself between the limbs. The foot and whole diseased
portion of the limb being enveloped in a cloth, is confided to the care of an
assistant.
2d. Ordinary Process — First step. — Armed with an amputating knife the
operator makes a circular incision through the skin, commencing at the crest
m
2S2 NEW ELEMENTS OF
and finishing at the internal border of the tibia, uniting by a second cut the
two extremities of this incision ; unless, by a rotatory motion of the hand upon
the handle of the instrument (a movement I have indicated abovej, he should
prefer to pass over without stopping the whole circumference of the limb ;
draws up with the left hand the integuments thus divided ; cuts their cellular
attachments, and raises them to the extent of an inch or an inch and a half; or
better, seizes them by their superior lip between the thumb and finger, near the
fibula, dissects them by rapid strokes of the knife or bistoury, and reverses
them quickly upward, so as to form a sort of collar or ruffle.
Second step. — After having applied the knife at the base of this collar or
circle of the skin, and upon the same point of the tibia as before, the operator
cuts backwards and outwards so as to divide the aponeurosis and all the
fleshy fibres above the level of the anterior interosseal fossa. By depressing
the wrist he divides the peroneal muscles in the same manner ; then, by
bringing it back gradually inwards, those of the calf or posterior face of the
leg ; again carries the instrument in front ; detaches the aponeurosis on each
side, and applies the heel of the knife immediately upon the external face of
the fibula ; draws it from heel to point, and when the latter reaches the in-
ternal face of the bone, obliges it to pass through the interosseal space ;
divides all the deep-seated fibres ; divides those which adhere to the external
face of the tibia whilst withdrawing the instrument ; carries the instrument
under the limb to the same point of the fibula ; brings it back upon its posterior
face ; passes again through the interosseal space, drawing it out in the same
manner as before ; divide all the muscles still remaining behind the tibia; and
thus he will find that he has traced out the figure 8 by his movements, as has
already been observed in the amputation of the fore-arm. It is well, as in this
latter member, to make a second incision with the bistoury upon each edge of
the interosseous membrane. Then pass from behind forwards the middle
strip of a three-headed bandage between the bones. The pieces of this bandage
suitably applied and brought together, are given to an assistant to draw up the
soft parts.
Third step. — The surgeon fixes the nail of the thumb at the point to which
the tibia has been denuded ; applies the saw upon this point and gives it a
few limited movements, then elevates the wrist so as to cut the fibula com-
pletely first, and finish upon the bone on which he had commenced ; because
the fibula alone would not offer sufficient resistance to the action of the saw,
and its superior articulation would be exposed to a serious concussion. This
second reason appears to me none the less conclusive, although the first is
sufficient to justify the precept. As soon as the fibula is divided, the assist-
ant holding the inferior part of the limb, and the operator holding the superior
part with his left hand, must compress it enough to prevent its being touched
or moved by the saw. M. Roux recommends it to be divided higher up than
the tibia. It is for this reason that he inclines the saw obliquely upwards and
outwards. By this means M. Roux proposes more surely to guard against the
consecutive projection of the fibula. It is of little importance. The section
of the two bones on a line is not sensibly less advantageous. I see still less
reason to imitate some surgeons who saw them separately. In fine, if the
surgeon should choose to operate on the outside instead of the inside, after
OPERATIVE SURGERY. 233
having formed a groove of a certain depth upon the principal bone, it will be
sufficient to direct the assistants to pronate the limb, and then depress the
wrist a little to render the division of the fibula more easy.
The anterior angle of the tibia upon which the skin rests, and against which
it is pressed by the force of the muscles of the calf which tends to draw it
backward, sometimes produces a perforation of this membrane. The surgeon
should have in his mind the means of combating such an accident, of which
the amputation of the limb at a high point is ordinarily a successful one. I
have seen MM. Richerand and Cloquet, at the Hospital Saint Louis, prevent
it when it was threatning, by applying upon the posterior face of the stump a
piece of pasteboard en forme d^atdles. A much more certain means is to
remove the angle or osseous edge itself by a cut of the saw. It is not known
to whom belongs the first idea of such an improvement. It has been used for
a long time by military surgeons.
Process of Sabatier. — The metliod of Sabatier differs from the foregoing
only in this ; he advises the operator to divide the anterior half of the integu-
ments of the member ; first, to draw them upwards and continue then the
circular incision behind somewhat higher up. The reason that he gives is,
that upon the calf of the leg tlie skin retracts with the muscles, whilst befor*».
upon the tibia and anterior aponeurosis, this does not take place. This modi-
fication, although not bad, is generally neglected.
Process of Dr. Physick. — C.Bell claims the honor of the invention of a
method which Dorsey gives to Dr. Physick. It is, to divide first the skin and
then the muscles of the calf very obliquely from below upward, so as to com-
plete the section much nearer the knee, upon the anterior half of the member,
and terminate the operation as in the ordinary manner.
Process of M. Baudens, or B. Bell. — After dividing the soft parts circularly,
M. Baudens advises us to detach all the muscles to the extent of one or two
inches, with the point of the knife held parallel to the axis of the bone. This
advice, given by B. Bell for amputation of the arm or thigh, for amputation
in general may be useful, and accords with that recentl}^ given by M. Hello.
Dressing. — In the place of election the operator successively seizes the
anterior tibial artery, which is in contact with the nerve, from which it is
necessary to separate it ; the posterior tibial, the peroneal, and some branches
of the gastrocnemials ; and sometimes, the nutritive artery of the tibia. Very
often the first of these vessels retracts far into the flesh ; the reason of which,
M. Ribes says is the double curvature which it undergoes to get before the
interosseous ligament. M. Gensoul, on the contrary, thinks that this retraction
appears to occur because the fleshy fibres surrounding it are too adherent to
contract; thus making the contraction of the artery appear much greater than
it really is, and much more so here than in the posterior parts, w^here the
muscles draw them up much higher. Witliout rejecting entirely the first of
these two explications, I freely adopt the second.
When the section of the bone is made immediately below the tuberosity of
the tibia, a single trunk replaces the posterior tibial and peroneal arteries, but
then the nutrient artery presents a considerable volume. Higher still the an-
terior tibial itself may not be separated from the popliteal, which in this case
requires only one ligature, with the inferior articulating and gastrocnemial
arteries.
30
f
234 NEW ELEMENTS OF
Surgeons do not all agree upon the mode of uniting the wound. In France
it is almost always done from within outward and from before backward.
Many English operators, Mr. Hutchinson among many others, still close as
formerly, e. e. directly from before backward, thereby hoping to escape the
stagnation of the fluids, and the pressure of the point of the tibia against the
skin. Again, there are others who, after the advice of ,Mr. Guthrie, unite it
transversely: but it is indisputable that when the operator has taken the
precaution of paring the bone, as it is called, the method of M. RicKerand is
the best ; that this alone permits the bringing together of the flesh into the
smallest space, and that this alone opposes in no way the flow of the pus.
If the amputation has been made very low, the limb must be supported upon
a cushion lightly flexed, and inclined upon its external edge ; sometimes the
stump is placed upon pillows, which very much relieves the ham, and prevents
the wound from coming in contact with the matrass.
The Flap Operation. — It was on the leg especially, that Lowdham, Verduin,
Sabourin, &c. wished their method applied. It was also on this part that
Garengeot, de la Faye, and Le Dran made their first attempts. But the ex-
ertions of Louis, Lassus, and Sabatier to disseminate the circular method,
and the apparently greater pain and difficulty of the flap operation, caused
the latter to be almost entirely renounced. M. Roux and Dupuytren, however,
again introduced it amongst us about twenty years ago. Dr. Hey in England,
Klein and Benedict in Germany, have also succeeded in introducing it among
some of their countrymen. It appears to have been rejected by the moderns,
especially on account of the volume of the tibia, ih^ internal face of which,
whatever plan may be pursued, can only be covered by the skin. The ne-
cessity of making the flap chiefly, if not entirely from behind, is another
motive for its rejection. However, as there may be cases that render it
indispensable, I feel bound to point out here the principles upon which it is
to be performed.
1. Process of Verduin, A two-edged knife, entered a little below the
point at which the saw is to be applied, is made to form a semilunar flap at
the expense of the calf, about four inches long ; bringing it in front you im-
mediately divide the integuments and muscles, as in the circular method, to
the base of the elevated flap; the interosseal parts are cleared, and the bone
sawn as in the ordinary method.
2. Process of Hey. — To be more certain of the length of the flap. Dr. Hey
advises us to make one circular line at half lieight of the tibia, a second
an inch below, and a third four inches below the first ; then two others parallel
to the axis of the member, one on each side, and which stretch from the union
of the two anterior thirds, with the posterior third of the superior circular
line, as far as the last. The first line indicates where the bone is to be
divided with the saw, the second where the integuments are to he divided
anteriorly, and the third the place where the knife must be stopped; whilst
the two lateral lines trace the form and extent of the flap, whicli Hey in other
respects formed like Verduin and Lowdham. No operators at present, I ima-
gine, will be tempted to use these architectural delineations and geometrical
rules.
3. Process of Ravaton. — The circular incision, made at four inches from
the place where the amputation should be performed, admits of another on
OPERATIVE SURGERY. 335
the face and near the internal edge of the tibia, then a tJiird upon the
external edge of the limb, which must fall at right angles upon the first.
The two square or trapezoid flaps, one anterior and the other posterior,
that result, are then dissected upwards and raised; nothing more remains
but to free the interosseal space, pass the compress, and saw the bone.
4. Process of Vermale. — To form the first flap, Le Dran, who is said to
have used the methods of Ravaton and Vermale successfully, pushed the
knife from the internal to tlie external face of the limb, and began by forming
the anterior flap ; nothing is then more easy than to force back the flesh and
make the posterior flap.
5. Process of M, Dupuytren, — Instead of beginning with the anterior flap,
M. Dupuytren passes the instrument between the posterior face of the bone
and the soft parts, taking care to leave more flesh than Le Dran, behind the
fibula.
6. Process of M, Roux. — As it is almost impossible to presei-ve as much of
tlie tissues before as beliind, M. Roux first conceived the idea of makinp;
upon the internal face of the tibia, an incision about two inches long, obliquely
forwards and downwards, beginning at the internal and ending at the anterior
edge of the bone ; when the posterior flap has been formed, tliis incision admits
of the bringing back of the edge of the wound easily to the level of iY.^ crest
of the tibia; thus making the anterior flap more regular and thicker.
All of- these methods may be reduced to that of Lowdham and that of
Vermale; one by a single flap, the other by two. When the skin is disor-
ganized much higher before than behind , and the amputation must be performed
very near the knee, the first is necessary. I have seen it used with success
by M. J. Cloquet, at the Hopital de Perfectionnement, on a subject who
without it must have lost his thigh. In all other cases the double flap method
appears to me most proper, although a little more difticult. When there is
only one flap, it must necessarily be bent at a right angle at its base to apply
it upon the bone. Immediate and complete union is almost impossible. It
is rare that it is not succeeded by very lively pains. The consequences that
may result from it, justify to a certain extent the fears of some surgeons, and
their repugnance to its performance. W^ith two flaps, on the contrary, the
wound closes very easily; the parts are neither bent nor stretched, and are
thus in the most favorable condition possible for immediate reunion.
7. Process of the Author — In trying upon the dead subject the method of
'ttermale, which I have once performed upon a living one at the Hopital St.
jQntoine, I neglect the little preparatory incision of M. Roux, but I take care
to embrace both sides of the limb with my left hand, and to draw as much of
the integuments as possible forwards. The point of the knife is then applied
upon the internal face of the tibia; brought to the level of the crest of this
bone, pushing the skin before it; slipped behind the interosseous ligament;
raised a little to pass behind the fibula, and again inclined backwards; whilst
the tissues are drawn towards the body of the operator until the moment it
passes through the external edge of the member. This flap finished, a similar
one is formed behind, and the rest of the operation performed without variation
from M. Dupuytren's method. By every method it is necessary that the in-
ternal angle of the wound should be a little lower than the external, if we
would not expose the bone to denudation or necrosis.
236 NEW ELEMENTS OF
2. In the Articulation,— History and Value. — Although vaguely indicated by
Hippocrates and Guy de Chauliac, a little more clearly mentioned by F. de
Hilden, the disarticulation of the leg never attracted much attention until tlie
latter part of tlie last century. At the present time, notwithstanding the
efforts of J. L. Petit, Hoin, and Brasdor, who endeavored to restore it, it is
not now recommended by any one : and M. Blandin is almost the only person
who has dared to reproduce the arguments of Brasdor in its favor. The
operation therefore at first view seems to deserve to be erased from modern
siu-gery. Is tliis a judgment without appeal ? I think not.
De la Roche tells us that a young girl, aged seventeen years, underwent an
amputation in the knee, and that she was perfectly cured. In one case men-
tioned by J. L. Petit, the disarticulation of the leg appeared only to have been
prefeiTed because of the want of instruments to amputate in the continuity of
the limb. Another was that of a young man, who had both bones of the leg exos-
tosed and carious throughout their whole extent. We have every reason to
believe that these two cases, of which Petit was only a witness, were amply suc-
cessful. , A slater who had fallen nineteen days before from a height of one hun-
dred and thirty-two feet, was taken to the Hospital of Dijon, July 26, 1764.
His leg was gangrened to the knee. Hoin disarticulated it, and although
tliere were not soft paiis enough to permit immediate union, this man was
ultimately cured. 'In the month of July, 1771, he was still alive, used his
wooden leg freely, and could mount the scaffold or roof as before the accident.
Gignoux, of Valence, speaks of a young woman who had had the leg separated
from the thigh by gangrene, and whose health was entirely restored in four
years. Sabatier is said to have seen a boy whose leg was carried away by a
ball without injury to the patella, and who suffered nothing serious from the
accident. In 1824, Dr. Smith, Professor of Yale College, in America, had
recourse to disarticulation in the case of a lady, who since has never ceased to
be able to walk witli a wooden leg. A scrofulous subject, aged nineteen years,
was operated on in the same way at the Hopital de St. Louis, in 1824, by M.
Richerand. Various accidents, some abscesses, and purulent fistulre of the
thigh, at first alarmed the surgeon, but the wound nevertheless ultimately
cicatrized. A man, amputated at the knee, was met with in the streets of
Paris by M. Dezeimeris, in 1829. This man walked freely, but with a cuissart,
and without using the stump as a point of support for the artificial member.
Dr. Bourgeois informs me that he has seen a similar case at Etampes. Rossi
regards it as the most simple method, and is said to have twice performed it
successfully. Finally, a case of disarticulation of the leg is mentioned in the
first volume of the Dictionnaire de Medecine et de Chirurgie Pratique. The
patient operated upon at the Hospital Beaujon died the sixteenth day after
the operation, from the consequences of phlebitis.
Here then are fourteen well authenticated cases of amputation of the leg
in the articulation, and of this number thirteen incontestable examples of
cure. It cannot be denied that these first results are very encouraging.
Amputation in the continuity has certainly never given more satisfactory
ones. To those who would object that in Gignoux and Sabatier's patients the
operation having been performed as much by nature as by surgery, nothing
can be concluded in favor of ordinary cases ; that gangrene had also per-
formed part of the amputation in Hoin's subjects; that that of M. Blandin
OPERATIVE SURGERY. QS7
ultimately succumbed ; that they were all young subjects, and that with all it
was a long time before they could use the stump ; it may be replied : 1st. That
if tlie wound closes well after tlie spontaneous separation of the limb, or when
gangrene had already attacked the tissues, there is no reason why it should be
otherwise in consequence of an artificial operation. 2d. That the accident,
of which one of the patients became the victim, belongs no more to disarticula-
tion than to the simple operation for amputation of the leg, and that his death
eight months after was the result of his primitive affection. Sc\, That there
is no evidence that there should be less to hope for in this operation with
adults than with adolescents. 4th. That the length of the cure must be
attributed to the peculiar circumstances, and not to the operation. 5th. In
fine, that Dr. Smitli did not complain of any of these inconveniences. But
let us contiuue the exposition of facts.
In the month of January, 1 8 ?0, 1 received at the hospital Saint Antoine, an
orphan, aged nineteen years, who was sent to me by M. Kapeler, chief physi-
cian of the house. The operation was fixed for the 14th of the same month.
As there were not soft parts enough behind, I thought it proper to preserve
enough in front for a flap of a given extent. The wound united but incom-
pletely. Noaccident followed; and although there remained a transverse
surface of about an inch in width antero-posteriorly, which the flap did not
cover, the cicatrix nevertheless was completed by the end of two months. At
present this subject enjoys sound health ; the stump supports the weight of
the body upon a wooden leg with the same facility as if it had been subject-
ed to an amputation in the continuity of the limb. A man, aged twenty-nine,
well made, born in the colonies, was sent to me in tlie hospital Saint Jin-
toine, the 24th of the following May, by Dr. Thierry, to be treated for a
comminuted fracture of the left leg. Gangrene soon manifested itself.
An ichorous suppuration more and more abundant, an excessive pain at
dressing and even during the intervals, and almost continual fever, diar-
rhoea, &c., soon supervened, and took away all hope of preserving the
limb. I tlien decided to amputate in the knee joint, and performed this
operation on the 4th of June. The fever of reaction, which continued high,
obliged me to bleed on the first and second day. Nothing of importance fur-
ther occurred up to the fifteenth day. On the sixteenth and seventeenth an
erysipelas supervened, and returned the fever. Notwithstanding this, in-
tercurrent phlegmasia, together with two purulent collections which afterwards
formed at tlie angles of the condyles, and derangements produced by errors
in diet — a true indigestion in fact — the cure was completed towards the
sixtieth day. At present this patient uses a limb of wood with the same
fiicility as the preceding patient. In the month of July, 1830, I had to ex-
amine, at the central bureau of the hospital, a young man, aged nineteen,
who had undergone an amputation seven years before, and who came to re-
quest a renewal of his wooden leg. He informed me that it was at the Ho-
pital des En/ants, to which he had been sent for grangrene, that he had sub-
mitted to the operation in the knee. The cicatrix is behind, and although
the internal condyle, an inch longer than the other, is the only part that presses
upon the artificial member, yet he moves about as well as if he had been
operated upon below the articulation. Since then it has been performed once
successfully by Mr. Nivert of Azai-le-Rideau, in a male adult who had had
238
NEW ELEMENTS OF
the limb fractured by a gun-shot. I have been told, liowever, that two other
operators have not had the same success. But I know from M. Blandin, that
the state of his patient scarcely left any hope before the operation, and I am
ignorant of the details of the other case. It was not so with tv/o subjects
upon whom I operated this year at La Pitie ; the one an old man, affected wdth
senile gangrene, died the 28th day, the mortification having renewed itself
upon the stump. The other a woman extremely ftit, with the limb suffering
from an enormous cerebroid cancer, w^hich did not permit me to preserve any
thing but the integuments on the inner side, was taken with a suppuration of
the entire thigh and a large ulceration on the sacrum. She died the sixty-
second day, without showing any thing wrong about the wound.
Instead of opposing experience, this gives high evidence in favor of this
operation. And what reason can there be opposed to it ? Will some object,
1st. That by uncovering such large osseous or cartilaginous surfaces it exposes
to very formidable consequences.^ As the continuity of the bone is not af-
fected, nor the periosteum destroyed, there is nothing to fear from the contact
of the air. The cartilaginous plate which envelopes the condyles is a
protection, quite insensible, that may remain for weeks entirely naked
without the least inconvenience. The synovial membrane that Bichat has
given it, does not exist. 2d. That it will produce an^ enormous wound,
which it will be almost impossible to cover with the adjoining soft parts ?
This is an error. This wound, so vast in appearance, is reduced by analysis
to the division of the integuments, several fibrous laminae, and some muscles.
Provided the skin can be saved for the extent of two or three inches, it will
always suffice for immediate reunion. Sd. That it is concerned with tissues
which do not readily inflame or admit of a ready and firm cicatrization, as
in the fleshy parts of the limbs ? There is an error prevalent on this point as
upon the other. Nothing is better than a tegumentary couch ; it is all that is
absolutely necessary to the formation of a good cicatrix. As it covers the
whole synovial surface of the femoral condyles, it will adhere as well, and
even more exactly, it may be said, than upon a divided bone and muscles.
4th. That it will be more painful, and attended with a less speedy cure than
the ordinary amputation This is not a more solid objection than the preced-
ing ; the facts above stated give suflacient proof of this ; and the more as the
subjects of it were certainly not all in the best condition for a prompt cicatriza-
tion of the wound. 5th. It is accused — and this reproach is the one upon
which objectors most insist— of leaving the patient in the same state after
the cure, as those who have been operated on at the thigh ; that is, of being
obliged to make use of a cuissart instead of a wooden leg in walking . I
confess that this apprehension for a long time arrested me. But it is useless
to refute it here ; the three patients upon whom I have already remarked, are
placed there to reduce it to its just value.
Why then should it be proscribed ? After the amputation of the thigh, no
matter how low down, the point of support for the artificial limb must be
taken upon the ischium. The movements of the haunch are almost entirely
annihilated. Progression is performed as if the coxo-femoral articulation
had been anchylosed. On the contrary after disarticulation of the leg
the point of support is the extremity of the femur. The thigh preserves all
its movements, and tjie patient is in the same condition as if he had a simple
OPERATIVE SURGERY. 239
consolidation or anchylosis of the knee. If it be true that as to the functions
of the member it is inlinitelj better to amputate in the continuity of
the leg than in that of the tiiigh, the advantages of disarticulation of the knee
must be equally beyond dispute, for ihe^ weight of tlie body is transmitted to
the artificial member in the same manner after the latter as the former. The
wound appertains almost exclusively to the skin, comprehending neither bone
nor aponeurosis ; the surface to be covered is convex, regular, deprived of every
kind of asperity, and there is no reason to apprehend muscular contrac-
tion. In the thigh, on the contrary, the solution of continuity comprehends
a great aponeurotic envelope, and all its concentnc plates; muscles nu-
merous, and of very considerable thickness ; of a bone which divides itself
with great facility, and the division of which produces a concussion which is
in itself not without danger ; and, in fine, of all the cellular tissues that unite
these various parts. At the knee only one artery of considerable size is di-
vided ; torsion and compression secure it almost as Certainly and as easily as
the ligature. At the thigh there are, besides the principal trunk, numerous
secondary branches, all requiring to be tied with care.
Thus, in theory as in practice, the amputation at the knee evidently offers
less danger than amputation at che thigh ; perhaps even than in the continuity
of the leg itself. I would say further, that the proofs indicate it to be less
dangerous than most other disarticulations, althougli up to the present time
it has been practised mostly after very vicious methods, or under verj disad-
vantageous circumstances-
Mamial,
The patella which J. L. Petit recommends to be removed, should always be
preserved; the contraction of its muscles elevates and soon fixes it above the
condyles, where it can interfere with neither the cicatrization of the wound
nor the use of the stump after the cure.
1. Process of Hoin. — The process of Hoin, carefully described by Brasdor,
and which consists in cutting through the articulation from before backward
below the patella, and finishing with a large flap made from the calf of the
leg, presents more than one inconvenience. The anterior lip of the wound,
drawn by the action of the muscles and the natural contractility of the tis-
sues, often mounts above the cartilaginous surfaces. Its angles, separating
by the lateral projection of the condyles, in spite of all that can be done,
soon leave a part of the bone uncovered. The flap, always thinner at its
root than towards its point, adapts itself badly to the parts it has to cover.
Besides which, the state of the tissues prevents us sometimes from giving it
sufficient size to reach, with ease, the retracted edge of the patella. In fine,
it'is rare that the cicatrix will be formed so high, that in walking or standing
it will not be exposed to pressure.
2. Process of Leveille. — In following the advice of Leveille, to form the
flap at the expense of the anterior soft parts, the operator can but rarely give
it sufficient extent to throw the cicatrix far enough from the resting point
of the condyles. This manner of operating has not been reproduced in any
other work of surgery than that of Monteggia, who barely mentions it.
3. Process of M, Blayidin, — Nor can I see what more is to be gained by
S40 " NEW ELEMENTS OF
commencing, instead of finishing bj the formation of a flap behind, nor the
advantage to be derived from making a counter-opening in the hollow of the
ham for the passage of the ligatures and pus, as proposed bj M. Blandin.
4. Process of Mr. Smith, — With the two flaps of Mr. Smith, or rather of
M. Beclard, I am assured bj M. Belmas, who assisted at the operation on the
cliild of whom I have spoken, it is not necessary to preserve so much of the
flesh in the calf of the leg. Being forced to pursue this method with my first
patient, I was convinced that it offered at least as many advantages as those
of Petit, Hoin, and Brasdor. However, whetlier by one or two flaps, nothing
can prevent them from contracting in extent as they increase in thickness,
and consequently leaving a portion more or less considerable of the condyles
entirely uncovered ; so that the cicatrix can only be completed by a tissue of
new formation.
Process ofPossi. — Rossi's method, which consists in making one flap inside
and another on the outside, instead of before and behind, although still more
vicious, should not be entirely rejected, especially when the skin is less altered
upon the sides than elsewhere,
New Process. — In the process that I have adopted, the skin is divided cir-
cularly at three or four fingers' breadth below the patella, witliout touching
the muscles. In dissecting it away to elevate and evert it, care must be taken
to preserve on its internal face all the cellulo-adipose layer with which it is
naturally thickened, and not to destroy its smaller blood vessels. An assist-
ant immediately draws it up toward the knee, until in dividing the rotular
ligament, the instrument can fall upon the inter-articular line; tlie sur-
geon then divides the lateral ligaments ; separates the osseous surfaces by
flexing the leg a little; detaches the semilunaj* cartilages ; divides the cru-
cial ligaments ; goes through the joint, and finishes by dividing at a single
stroke, the vessels, nerves, and muscles of the ham, in a direction perpendi-
cular to their length, and on a level with the elevated integuments.
Dressing. — After having tied or twisted the popliteal artery and the less
important branches that may require it, the operator turns down the whole of
the dissected skin, cleans, and, if he intend immediately to unite them, brings
the two sides together so that the angles of the division may be tranverse.
But if the union should not be at once attempted, a fine piece of linen, covered
with cerate and pierced with holes, should be applied over the whole solution
of continuity, which is then filled with lint, and the whole covered with soft
pledgets, and enveloped in an ordinary bandage.
By this method the integuments represent a kind of purse or nifile, which
envelopes and covers the condyles as well at the sides as before and behind.
As it is a little smaller at the mouth than in its depth, it is similar to a sleeve
somewhat tight at the wrist ; and consequently offers some impediment of
itself to its retraction upon the thigh. The muscles are divided squarely, and
where they are very small, present but a very small bleeding surface ; leave
the skin free, and cannot aggravate the traumatic inflammation or excite any
just fear of too abundant a suppuration, as in other methods. In fine, the
ligatures, if they are used, are easily applied; and collected at a point so
<listant from the vessels which they secure, and in such a manner as to irritate
but little the interior of tlie wound.
I would not however conclude from these data, that all otlier methods
OPERATIVE SURGERY. 241
should be henceforth abandoned as useless. If the skin be too much altered
before, whilst it is otherwise behind, it would be better to use Petit's method.
Smith's process will be in some sort necessary, if the disorganization, being
liigher on each side towards the condyles than an tero -posteriorly, has already
traced the limits of the flap. But in other cases, whenever circumstances
admit of choice, I will venture to say that the circular method offers the
greatest advantages, and should be generally preferred.
Art. 9.— Thigh.
§ 1. In the Continuity.
Place of Election. — It is not with the thigh as with the leg; here the ampu-
tation should be as low as possible. The greater the length of the stump, the
more easy is it to apply the substituted apparatus. The operation, already
one of the most dangerous class, is still more dangerous the nearer we approach
the trunk. It is then astonisliing, that M. Langenbeck should recommend it
never- to be performed below six fingers' breadth above the knee; alleging, as
the pretext, that lower down the artery is confined in the sheath of the abduc-
tors, and that it will be difficult to draw it out for ligature. As the femoral
artery may be reached above or below the fibrous canal which it traverses, or
even in the canal itself, it can in no case be difficult to seize, nor require an
after-division of the sheath which encloses it. On the other hand, as it is rare
that the disease permits the division of the integuments at less than two or
three inches above the patella, the section of the femur must almost always
be more than five inches above the articulation, and therefore the precept of
M. Langenbeck is useless.
Anatomical Remarks. — In the thigh, as in the arm, tliere are found two
beds of muscles, one superficial, composed of the rectus, the sartorius, the
gracilis, the semitendinosus, the semimembranosus, and the long portion of the
biceps ; the other deep-seated, comprehending the three parts of the triceps and
the abductors. The first extend from the pelvis to the leg, eacli one in a sort of
distinct cellular sheath, which permits them to move easily beside each other,
and consequently enjoying very great contractility. The intimate connexion
of the others with the bone, on the contrary, allows them but slight retractile
power ; hence it is the superficial layer only which contracts after amputation,
so as sometimes to leave the femur uncovered and projecting. Near the pel-
vis, we find, besides the psoas and iliacus, the great gluteal, and the pecti-
neus ; then quite high up the other two glutei, the obturatores, the gemini, the
pyriformis, and the quadratus, which, by the great separation of their points
of origin, tend much more to enlarge the wound than to denude the bone, if
the amputation be performed between the lesser trochanter and the hip joint.
The femur, bending slightly forwards near its middle, is enveloped at this
point by a bed of soft parts less thick, and by muscles much less retractile be-
fore than behind. From which it happens that the cicatrix forms almost al-
ways more or less inwards or backwards, and that the extremity of the bone
never corresponds to the centre of the stump in those amputated at the thigh.
The crest which the bone presents posteriorly, easily splinters under the
action of the saw, and consequently requires much care during that part of,
the operation.
31
242 NEW ELEMENTS OF
The femoral artery is the only one of importance met with in the lower
part of the thigh. As it is covered by the sartorius, it is always easy to
find. However, the anastomotica magna must not be forgotten. It is some-
times enveloped by the tendinous fibres of the great adductor, the direction
of whicli it follows, and it is in such cases very difficult to isolate. The deep-
seated muscular or perforantes, and, nearer the pelvis, the superficial muscu-
lar and circumflex arteries, must be added to the crural ; the first over the
anterior of the adductor muscles, or in the midst of them ; the second under
the rectus ; the other tvVo, inside and outside, a little above the lesser tro-
chanter
The femoral vein is connected with the artery in such a manner that the
precautionary compression of the latter prevents the return of blood by the
former; thereby often producing hemorrhage. The great sciatic nerve, loose
at tlie posterior part of the thigh and anterior to tlie superficial muscles, devoid
of all contractility in itself, sometimes hangs out from the wound, beyond
which it may project more than an inch, and thereby render the dressings very
painful. In such a case the best thing to be done is, as recommended by M.
Discot, to cut it oft* at once. Another branch of the nerve that requires some
attention, is that which attends the crural artery. Its diminutive size prevents
it from being readily distinguished. Yet, by remembering that it is always
upon the anterior and internal face of the artery or vein, an operator will not
be much embarrassed in finding and putting it aside.
Manual.
A. Circular MetJtod. — All that has been said of the circular method in
general applies particularly to this. As it is of all amputations in continuity
the most serious and alarming, it is to this that F. dfe Hilden, Wiseman,
Pigray, J. L. Petit, Le Dran, Louis, Pouteau, Valentin, Alanson, Hey,
Desault, &:c. have particularly referred, in their discussions upon the ablation
of the members.
Position of the Assistants. — Placed upon the foot or edge of his bed or a
table, with the thigh free to its root, the patient is held by four or five assist-
ants ; one for the head and arms, another for the pelvis, a third for the sound
limb, a fourth for the leg of the affected side, and a fifth to draw up the tissues.
The tourniquet, or the garot, which some persons still use, and every kind of
bandage m hich was formerly applied above the point of division of the flesh to
prevent hemorrhage, should be rejected, as preventing, or at least lessening tlie
contraction of the muscles. The practice of Girardeau, adopted by almost
all modern surgeons, and wliich consists in compressing the artery upon the
body of the pubis, since it does away with this objection, merits the prefer-
ence that it has generally received. It will be inexcusable to follow the an-
cient method, unless under special circumstances in the case, or for want of
sufficient assistance. In every case the tourniquet should be placed as high
as possible. According to S. Cooper, in order that the left hand may always
embrace the thigh on the side next its origin, it is the practice in England for
the operator to place himself always on the right of the patient ; so that in the
amputation of the left thigh the sound member is placed between him and the
one to be removed. I need not assign the value of such a precept ; every
OPERATIVE SURGERY. 243 .
surgeon amongst us will give it what it merits. In France the operator
places himself on the outside for both limbs, and consequently, when operating
on the left, he must leave tlie retraction of tlie integuments to an assistant.
The first incision, which comprehends as nearly as possible the whole
thickness of the integuments, is begun above the knee at four or five fiihgers'
breadth from the point at which the division of the bone is to be made..
Whether the aponeurosis and the subjacent muscular fibres be reached or not,^
is of little importance; the chief matter is the complete division of the skin."
In endeavoring to favor its retraction, it should be remembered that it adheres
much more firmly to the aponeurosis, on the anterior part of the thigh, than
elsewhere.
Second Step, — Tlie knife, again placed at the edge of tlie retracted integu-
ments, is made to cut the muscles, if not to the bone, at least through the super-
ficial bed. After the retraction of this part, the surgeon again applies the
instrument upon the base of the cone formed by these divided parts, and with
another cut divides the remaining fleshy fibres; he then denudes the bone,
applies the defensive compress, crossing the strips anteriorly, incises any
tissue that may yet remain attached to the bone, and then finishes with the
saw.
Above the middle of the limb the muscles contract much less ; but as the
volume of the member is more considerable, it is equally necessary to com-
mence three or four inches below the point at which the saw is to be applied.
Perhaps there would be some advantages when the operation is nearer the
hip, in using M. Graefe's knife, in order to make a kind of funnel of the soft
parts, or else divide them, as Alanson and M. Dupuytren do, by inclining the
edge of the instrument upwards. In fact, a perpendicular division produces
a wound so square or level, that it is sometimes very difficult to bring its
parts in contact. But this inconvenience is easily obviated, by taking the
precaution to dissect the skin for two inches, and evert it, instead of merely
dividing the cellular filaments that connect it»with the aponeurosis, as in
the process of Desault. I have seen M. J. Cloquet, in the case of a young
subject at the Hopital de Perfectionnemenf, on whom he was obliged to operate
at a short distance from the great trochanter, unable to produce immediate
union, from having neglected this precaution. The same thing has happened
to myself.
The arteries to be tied or twisted in the lower part of the thigh, are the
femoral, the great anastomotic, and some articular branches, or those of the
last perforating. The number augments as we go up ; so that in the hig;her
parts there are the profound femoral, the superficial muscular, some branches
of tlie circuiafiex, the obturator, and the ischiatic. To give easy escape to
the matter formed, French surgeons give the wound such a direction, that one
of its angles presents anteriorly, wliilst the other is immediately behind.
Some of the operators of Great Britain blame this plan as vicious, because the
posterior angle must necessarily come in contact with the cushions or matrass.
Among others, Dr. Hennen recommends an antero -posterior coaptation of the
tissues, thus giving the wound a transverse direction. But without being
absolutely necessary, the French method is best. For the position of the stump
after dressing, I refer to what has already been said a.bov^
Flap Operation. — As by the modern processes, the circ^r amputation, well
244 NEW ELEMENTS OF
performed, generally admits of the coaptation of the lips of the wound, and
of immediate union, the flap operation has not been tried in such a variety of
ways above as below the knee. In spite of the advantages which Ravaton,
Vermale, Le Dran, and Desault are said to have obtained from it; notwith-
standing those which Paroisse obtained from it on the field of battle ; although
the seven individuals spoken of by Kleim, were almost completely cured in
ten days ; and although many other surgeons, both English and German, have
used it of late with much success, still it is but very little employed. It is
objected, that it is longer and more painful — which objection, in my opinion,
has to be proven ; that it requires a greater extent of sound parts — an objection
perhaps a little more correct ; and that it exposes the patient to more serious
consequences — and this again is perhaps just. I have never attempted it but
once ; the bone escaped by the superior angle of the wound, and the patient
died. Some surgeons, Mr. Guthrie for instance, who prefer the circular
operation under other circumstances, have yet recourse-to tlie flap operation
when it is necessary to amputate in the superior third of the thigh. It then
certainly offers incontestable advantages for the approximation of the lips of
the wound.
1. Process of Vermale. — Nothing could induce us at the present day to
practise the three incisions of Ravaton, to form the flaps that may be needed.
It is infinitely more simple to cut at once through the whole thickness of tlie
member, as advised by Vermale. The patient and assistants being disposed
as before, the operator places himself on the outside for the right, and on the
inside for the left limb (this position however, he is not bound rigidly to
follow ); seizes the flesh with liis left hand, and draws more or less from the
bone ; plunges in a long knife till it reaches the anterior face of the femur at
some lines below the point where it is to be divided ; inclines the point of the
instrument slightly so as to graze the external side of the bone ; then immedi-
ately after gives it its original direction, so as to pass it out at a point dia-
metrically opposite the one at which it entered; and then, by cutting
downwards and outwards, forms the external flap, of about three or four
fingers' breadtli in length, which the assistant immediately raises. The
knife is again brought to the anterior angle of the wound, and, the fleshy parts
forced away from the axis of the body, it is made to glide along the internal face
of the femur, care being taken to carry it behind this bone without cutting
the soft parts a second time ; and the operation is finished by making a
second flap of the same size and form as the first. If, to adopt Dr. Hennen's
ideas, the operator wishes to give the incision a transverse direction, the flap
operation may still be used ; but it will be necessary to make one of these
flaps anterior and the other posterior, instead of internal and external. I
prefer to begin with the external flap, because, there being less to divide on
this side, it is necessary to draw them out as much as possible, that there may
not be too much difference in the thickness of the two flaps, and especially
because, in this way, we may, if necessary, dispense with the compression of
the artery at the inguinal space, since it is not divided until the very moment
of the completion of the flap.
2. Process of M. Langenbeck. — Instead of commencing the operation by
puncture, and then cutting outwards the skin, Langenbeck cuts from the
tegumentary tissulP towards the bone. The operator places himself on the
OPERATIVE SURGERY. 245
inside for the right limb, and the outside for the left member, unless he be
ambidexter; has the skin drawn upward by an assistant ; seizes the knee him-
self with one hand, and, with a knife of moderate length in the other, divides
with a single stroke all the soft parts which cover the inner face of the femur
from below upward, and from the superficial towards the deeper parts, so that
his instrument may reach the bone at not less than three inches above the point
at which the incision in the integuments was commenced. An assistant
then elevates this flap. The operator passes the fore-arm behind, then out-
side, and then before the thigh, and by a second incision cuts externally an-
other flap similar to the first, taking care to connect its semilunar extremities
with those of the internal incision.
In both these processes it is necessary, after making the two flaps, to carry
the knife to their base, and divide the soft parts that may yet remain attached
to the bone, so that the saw m.ay be applied as high up as the point to which
the knife has reached.
It is evident that the operator may content himself with one flap, either
internal or external, anterior or posterior, if the state of the skin does not
allow room for a second opposite the first, and that all the peculiarities
belonging to the flap operation in general apply to that of the thigh in parti-
cular. M. Baucel, who is said to have followed the process of Vermale in
every particular, is affirmed to have been sixty times successful. M. Hello,
%vho at the suggestion of M. Fouilloy made but a single flap out of the anterior
soft parts, maintains, with justice in my opinion, that his method has the
advantage of more decidedly opposing the projection of the bone than any
other, because the parts are drawn by their own weight over the whole extent
of the wound. I doubt, however, if the circular method, well performed, may
not be preferable to all these, which should be preserved, as I think, only as
exceptionary methods.
In Contiguity.
History and Value. — Morand appears to have had the first idea of amputat-
ing the thigh at the articulation, and to have been the first to conceive the
possibility of success in this formidable operation. Two young practitioners^
eleves of Wolher, surgeon to the horse-guards of the King of Denmark, that
surgeon himself, Puthod de Nyon, in Switzerland, made the first formal
proposition of it to the Academy of Surgery, the 3d of March, 1739, and
obtained a favorable report the 26th of July, 1740, from Le Dran and Guerin.
Ravaton would have put it in practice in 1743, if some of his compeers,
called in consultation, had not opposed it. The 7th of March, 1748, Vallum
sustained a thesis of Lalouette's upon the subject, which Morand succeeded
in opening to a concoiirs, in 1756 ; and again in 1759, the academy, not having
found any w^ork the first time worthy the prize proposed, thirty-four memoirs
were received, and that of Barbet crowned. Goursault, Moublet, Le Febure,
Puy, and Le Compte, also, have each published a work on the disarticulation
of the thigh. Almost all came to the conclusion that it was practicable;
some after attempting it upon the dead subject, others from experiments made
on dogs. Barbet sustained its practicability from analogy, and upon its
result upon an infant, aged four years, affected with gangrene from the use of
246 , NEW ELEMENTS OF
ergot, who first had the right, and then, four days after, the left tliigh ampu-
tated by Lacroix d'Orleans, in the presence of Le Blanc, and who appeared to
be on the point of being cured, but eventually died fifteen days after the
operation. Perrault of Saint-Maure, in Tourain, was obliged to imitate
Lacroix, in 1774, on a subject named Gois, who had had the thigh crushed
between a wall and the pole of a coach, and rendered grangrenous almost to
the hip. This patient, of whom Sabatier gives us the history, was cured,
and for a long time continued to be a cook in an inn, at Saint-Maure, where
I myself saw his son, in 1815. Kerr, according to S. Cooper performed the
same operation, but unsuccessfully, about the same time, upon a girl aged
fourteen years. Pott and Callisen having reprobated it, Bilguer, Tissot, &c.,
in vain defended it; and at the commencement of the present century it was
considered almost out of the question in England and Germany. It was in
the French armies that it was subjected to sufficient proof. M. A. Blandin
cites three cases of it. He operated on the first of his patients in the month
of Fructidor, year III, and completely succeeded. The second was equally
successful, and the third did not die until the fifty-eighth day. At the same
time M. Perret, another military surgeon, performed one successful ope-
ration. In 1798, Mulder was not less happy with a girl aged eighteen years.
In 1803, M. Larrey had already disarticulated the thigh several times, and
his memoirs contain two well -authenticated cases of success; one upon a
Russian at Witepzk, the other upon a French soldier at Mojaisk. According
to M. Gouraud, Dr. Millengen had two successful cases, which he published
in London. M. Baifos attempted it in 1812, at the Hopital des Enfants, upon
a subject aged seven years, who was cured of the operation, although it died
some months after, from the continuance of the scrofulous affection of the
joint. A soldier, wounded at Merida,and operated upon by Mr. Brownrigg,
so far recovered that he returned to England, where many persons have since
seen him. M. Cloquet saw a French prisoner, in 1815, at Val de Grace, who
had been operated upon in the same manner, by Mr. Guthrie. Another
successful case in France was produced by M. Delpech, and two others in
England, one by Sir A. Cooper, in 1824, the other by Mr. Orthon, in 1826.
Dr. Mott, of New York, published another, in 1827, and M. Wedemeyer
still another. Mr. Lyme's patient, in 1825, was cured in thirty-four days.
Mr. Bryce's, in 1825, who was near perisliing from hemorrhage, was met
some months after by this surgeon, at Poros,in perfect health. So that up to
the present time, this operation, which M. Richerand for ten years would
scarcely admit as possible, counts near twenty well-authenticated cases of
success. But during the same time, how often has it been followed by death?
Thompson, Kerr, A. Blandin, A. Cooper, Broocke, Cole, Walther, Larrey,
Guthrie, Emery, Dupuytren, Blicke, Krimer, Gensoul, Clot, Roux, &c., have
each had the misfortune to see at least one of their patients succumb to it.
The second operated upon by M. Delpech, died in about two months. One of
those, of Mr. Pelikan, of Wilna, died in ten, the other in sixty days. M.
Dieffenbach's survived but ten hours. I performed it once myself, and the
patient died on the fourteenth day. We should then only decide upon this
amputation, when it is difficult to amputate with some chances of success in
the continuity of the limb. M. Larrey seems even to prefer it when it would
be possible to saw the bone between the lesser trochanter and the articulation .
OPERATIVE SURGERY. 247
I am entirely of his opinion upon this point. The case I have spoken of as
occurring to myself, and two amputations of the latter kind which I was
forced to perform, have convinced me that he is right. My patient was in
such a state of exhaustion when he submitted to the operation, and the disorder
had extended so far towards the pelvis, that I could scarcely comprehend how
he could have existed even for a few hours under so many lesions. The cases
of Barbet, Kerr, Baffos, and Delpech, failed from the progress of the primary
affections, and not in consequence of the operation. In the other cases the
disease was so serious, that the simple amputation of the thigh in continuity
would probably have been followed by the same fate, had that onei-ation been
performed.
Hence, a comminuted fracture, necrosis, caries, osteo -sarcoma, spina-
ventosa, or any incurable alteration of the femur extending to the head of
the bone ; gangrene ; every disease, in a word, which may attack the hip, and
be sufficiently serious to require amputation, calls for this operation, provided
the articular cavity and the bones of the pelvis are not affected. Wounds
from fire-arms, with lesion of the bone in the superior third of the thigh, give
the most formal indication. As it is then necessary to use the knife at a
certain distance above the disease, I can see no reason to hesitate in attempt-
ing it. Reason, and the facts already known, lead to the belief that, all other
things being equal, it is not more dangerous than amputation in the upper fifth
of the femur. It is more easily performed and much more prompt. The sur-
face of the wound is not larger. The same muscles and the same vessels are
divided, and there is less of the tissues necessary to obtain co-aptation of the
parts. If practised in cases less desperate, I am convinced it will be attended
with very considerable success.
Anatomical Remarks. — The head of the femur, forming more than a hemi-
sphere, is enveloped in such a way in its fibrous capsule, that it will continue
to be held by it unless the capsule be divided near the edge of the socket. The
circumference of its transverse plane, upon which the axis of the neck of the
femur falls obliquely outward, downward, and backward, having to be traced
round with the knife at the moment of the operation, should never be lost
sight of. The position of the internal ligament is such that, by turning the
limb outwards, it presents itself at once to the edge of the knife. If the ope-
ration be commenced on the external side of the articulation, it is true that
this ligament becomes relaxed in proportion as the thigh is inclined inwards ;
but as it in no wise prevents the luxation, it is very easily divided on the
inner edge of the cavity.
Covered by the psoas and iliacus muscles, a little on the outside by the rectus
internus, by the pectineus, the vessels and nerves on the inside, the coxo-fe-
moral articulation is more superficial before than in any other direction, and
corresponds to the junction of the middle with the external third of Poupart's
ligament. Behind, it is separated from the skin by a considerable space,
which is filled by the third abductor, the quadratus femoris, semitendinosus,
semimembranosus, biceps, the obturators, the gemini, and pyriformis muscles,
of the cellular tissue, the great sciatic nerve, and some vessels. A triangu-
lar space, filled by the gluteal muscles and facia lata, limited by the great
trochanter below, and by the external iliac fossa above, removes its external
side from the skin, whilst the great trochanter itself is almost naked beneath
248 NEW ELEMENTS OF
the integuments. Internally there is found a kind of gorge or hollow,
formed by the concavity of the neck of the femur, which descends as low as
the lesser trochanter, filled by the principal mass of the abductors, the gra-
cilis, the end of the psoas and ilacus, and which obliges us to seek the cap-
sule on a plane much nearer the symphysis pubis, and much higher than the
axis of the member would seem to indicate.
The lines drawn from the anterior-superior spinous process of the ileum, from
the great trochanter or spine of the pubis, to measure the distance whicji sepa-
rates these difierent points' of the articulation, and upon which M. Lisfranc
especially insists, should not be neglected in an embarrassing case ; but the
preceding indications will generally suffice for a surgical anatomist. The
great and little trochanters, and even the head of the femur, continuing carti-
laginous until the tenth or fifteenth year of age, may if necessary be divided
by the knife, if there be any difficulty in turning their prominences in such
young subjects. The anomalies presented by the cotyloid cavity, the tube-
rosity of the ischium or the neck of the femur, and the projections near its
base, regard only the length, projection, or inclination of these different
objects ; so that they rarely cause any real difficulties at the moment of dis-
articulation.
§ 1. Manual.
A. Circular Method. — 1. English Process. — Abernethy appears to have
been the first to think that the amputation of the thigh in the articulation
could be performed by the circular method. This surgeon compresses the
artery on the body of the pubis ; divides first the skin and then the muscles at
some inches below the joint; separates the flesh from the great and little tro-
chanter; opens the capsule ; divides the inter-articular ligament ; dislocates
die bone ; ties the different arteries, and concludes by uniting the lips of the
wound antero -posteriorly with adhesive plaster, to maintain them in contact.
Mr. CoUes is not the only one who has practised Mr. Abernethy's method
upon the living subject. M. Krimer has also followed it. Dr. Weitch, who
also prefers it, exposes the femur before seeking the articulation for two or
three inches downward, below the incision of the soft parts, in order to use it
afterward as a lever to disengage it from its cavity ; a useless precaution, for
it is always possible to move the member with sufficient force in any direction
after dividing the capsule.
2. Process of M. Grsefe. — The circular method is equally praised by M.
Graefe, who also applies it to almost all disarticulations, and claims the honor
of its invention. At the thigh, as at the shoulder, he makes use of his large
knife to divide the flesh, and penetrates from below upward from the skin to
the head of the bone, in such a manner as to scoop out a hollow cone' as regu-
larly as possible. Having remarked that the head of the femur is sometimes
difficult of dislocation, M. Grsefe recommends the incision of the cotyloid
cartilage upon the notch of the same name ; but if the operator takes care to
divide the fibrous capsule exactly over the largest circle of the joint, there
will be no danger of the inconvenience that he apprehends, and which, accord-
ing to S. Cooper, detained a celebrated operator of London nearly half an
hour in the disarticulation of the thigh.
B. Flap Operation. — The method by the flaps has almost always been pre- ,
OPERATIVE SURGERY. 249
ferred for thi s amputation. A variety of different methods have been invented.
I shall not speak of those of Ravaton, Moublet, or of Petit Radel, because
they are too difficult or too complicated. Barbet, Penault, and M. Baffos,
having as it were only finished what nature had begun, do not present us with
a process to be described.
1. Process of Lalouette. — In a thesis sustained under the Presidency of
Lalouette, we find indicated one of the best processes that can be followed.
It should be commenced, says Louis, who reproduced it, by a section
almost sfemicircular at the external part of the thigh, in order to disarticulate
the femur before any thing else, and then to finish by an incision of the inter-
nal part, preserving a flap of four or five fingers' breadth. The candidate M.
de Vallun, described it as follows : the artery is compressed with a tourniquet ;
the patient placed upon the healthy side, the operator makes a semicircular
incision, commencing over the great trochanter, ending at the tuber of the
ischium, and penetrating to the articulation. With a second cut he opens the
capsule, whilst the assistant carries the member inward ; luxates the femur ;
divides the rest of the capsule, and terminates by making a greater or smaller
internal flap, adapted to the embonpoint of tlie patient. M. Lenoir, assistant
anatomist to the faculty of Paris, who has recently reintroduced this prac-
tice, employs an assistant to compress the artery, who compresses it in tlie
flap with the thumb as soon as the incision is completed. The rest of his de-
scription is so exactly similar to that of Vallun and Louis, tliat I think it use-
less here to repeat it.
2. Process of M. Plantade. — Many persons have thought that it would be
better to place the flap altogether in front, than upon the inner side of
the thigh. M. Plantade, who was one of the first to suggest it, recommends
the making of three incisions after the manner of the scapulo -humeral flap
of de la Faye, opening the articulation by its internal face, and finish by
forming a very small posterior flap.
3. Process of M. Manec, — In April, 1831, M. Manec showed me, on a
dead subject, a modification of the method of M. Plantade. The knife, placed
upon the centre of the space that separates the iliac spine from the great tro-
chanter, is carried downwards and inwards, between the flesh and the anterior
internal face of the neck of the femur, so as to pass out before the ischium,
and at once form a large flap, the free edge of which presents in a semilunar
form downwards and outwards. The assistant immediately seizes this flap
and elevates it, taking care to compress the artery, if the operator should not
prefer to tie it before proceeding further. To conclude, M. Manec divides
the external and posterior soft parts, by means of the semicircular incison of
Moublet, before disarticulation, or he first opens the joint, and make this in-
cision last. M. Lenoir, who also praised this method, recommends, and I think
correctly, that after the formation of the flap we should always finish the
division of the soft parts, as in performing the circular operation, before pro-
ceeding to the disarticulation.
4. Process of Dr. Ashmead, — A distinguished young surgeon of Philadel-
phia, Dr. Ashmead, also imparted to me in the montli of April, 1831, a pro-
cess founded upon the same ideas as the preceding. Like M. Manec, he gives
his flap a semilunar form. Like M. Plantade, he cuts from the skin towards
the deeper parts. After dividing the integuments at the point indicated, he
32
250 NEW ELEMENTS OF
seeks the arterj, and ties it. Relieved from the apprehension of hemorrhage,
he proceeds to the section of the muscles ; having reached the capsule, he dis-
articulates the femur, and finishes like Plantade or Manec.
5. Process of M. Delpech. — M. Delpech's manner of operating, is one which
gives a result almost exactly similar to that of Lalouette. This professor ties
the femoral artery at its escape from under the crural arch ; then makes an
inner flap, by plunging the knife at once from before backwards between the
neck of the femur and the soft parts, and bringing it downwards in the
direction of the skin, with greater or less rapidity. The flap thus formed, is
seized and elevated by an assistant. The operator makes a semilunar incision
at the base ; reaches tlie inner side of the articulation ; divides the capsule and
inter-articular ligament; brings back the thigh to its natural position ; makes
a semicircular incision below the external iliac region, and thus unites the
anterior and posterior extremities of the flap ; divides the three glutei, the
obturator intemus, the pyriformis, and the gemini muscles, and the external
face of the capsule. The tying of the arteries and dressing, concludes the
operation. M. Delpecli insists, tliat with a single flap immediate union is more
easy and sure. Slight pressure, he says, obliges the flesh to mould itself to the
cotyloid cavity, thus preventing inflammation, suppuration, exfoliation of the
cartilage, and fistulas. Moreover, as the flap presents a very oblique cut, he
recommends that the section of the integuments towards Hie outside should
be made a little higher than that of the other parts, in order that there may not
be too much skin, and that the coaptation, which he aids by means of a suture,
may be more perfect.
6. Process of M. iMrrey. — Le Febure, who wrote to Louis, in 1760, tj
announce to him the result of his researches, had conceived the idea of tying
the femoral artery in the groin. M. Larry has given this as a precept, which
permits the surgeon, he says, to act with more security, and causes the patient
to run much less risk. The artery being tied, the operator, placed on the out-
side of the member, passes the point of a long knife at two or three fingers'
breath below, and inside of the anterior-superior spine of tlie ileum, so as to
fall upon the anterior face of the bone ; inclines it a little inwards, and
slides it upon the internal face of the neck of the femur, and thus conducts it
backwards, until it again passes through the skin in the sub-ischiatic groove ;
cuts aninternal flap about four inches long, in the same manner as M. Delpech ;
causes this flap to be elevated ; divides the capsule for half its circumference
at least very near the cotyloid cavity, as if hewould cut through the middle
of the head of the femur, without attempting to enter the articulation ;
abducts the member ; divides the internal ligament ; passes the knife
about the external side of the sphere of articulation ; finishes the section
of the capsule ; arrives at the tendons of the glutei beliind the great tro-
chanter ; inclines the knife flatwise, by directing its edge downwards ;
grazes the extenial face of the body of the bone, and forms a second
flap as much as possible like the first. All the arteries being tied, the two
flaps are Ui'ought together, taking care to leave the ligatures in the posterior
angle of the wound to serve as a conduit to the matter formed.
7. Process of M. Blandin, — It appears tliat the double flap method had
been a long time in use when Larrey made his publication, in 180S. That of
M. Blandin, a method that this operator had used as early as 1795, consists
OPERATIVE SURGERY. 251
in first tying the artery, and tlien making the first flap like Mr. Larrey; but in-
stead of continuing from within outward, like the latter, M. Blandin makes his
external flap before touching the capsule and proceeding to the disarticulation.
8. Process of M. Lisfranc. — M. Lisfranc makes use of a narrow two-edged
knife ; plunges it from before backwards on the outside of the neck of the
femur, turns about the great trochanter, and thus begins by forming a flap
three or four inches long ; placing his instrument again at the superior angle
of this incision, he inclines the point a little inwards, to glide over the nock of
th^ bone ; immediately elevates the handle ; draws the ilesh inwards, so that
the knife may pass out under the ischium without again touching the integu-
ments ; divides all the tissues (without leaving the os-femoris), as far as the
lesser trochanter ; turns this osseous process ; directs an assistant to embrace
the origin of this second flap, by thrusting his thumb into the wound and thus
-compressing the artery, and terminates the section of the internal soft parts,
vas M. Larrey does ; ties all the vessels, and then disarticulates the limb.
9. Process of M. Dupuytren. — The surgeon places himself on the inside of
the limb, and uses, if ambidexter, the right hand for the right, and the left
hand for the left side; has the integuments drawn towards the pelvis; sup-
ports the thigh himself, inclining it more or less towards flexion, extension, or
abduction; makes on the inside a semilunar incision with downward con-
vexity, commencing near the anterior superior spine of the ileum and ending
near the tuber of the ischium; divides at first only the skin, which an assist-
ant then retracts ; immediately divides the muscles in the same way, thus
forming an internal flap four or five inches long; causes this to be elevated ;
attacks the capsule, like M. Larrey ; passes through the articulation, and
finishes v/ith an external flap.
10. Process of Beclard. — Placed on the outside of the hip, Beclard began
by cutting an external and posterior flap, by thrusting his knife obliquely
inward and backward, from near the iliac tubercle to the internal extremity
of the sub-ischiatic notch, and touching the posterior sides of the neck of the
femur. A second flap must be formed in the same manner before, in order to
finish by the section of the capsule and disarticulation. Dupuytren and
Beclard content themselves with the compression of the artery on the hori-
'zontal branch of the pubis.
11. Process of Mr. Guthrie. — Two semilunar incisions, one antero -internal,
the other postero -external, extending from near the iliac spine to near the
tuberosity of the ischium, where they meet, characterize Mr. Guthrie's method.
This surgeon first divides the integuments ; raises them; carries the instru-
ment to the edge of the retracted skin, and divides the muscles obliquely
upwards ; reaches thus the articulation after making two flaps, and terminates,
like MM. A. Blandin, Abernethy,, Lisfranc, and Beclard. It is evident that
the English surgeon's method differs from that of Beclard only in dividing
-the tissues from the skin towards, instead of the reverse; but it is in this very
difference that we find its real advantages.
C. Oval Operation. — The oval operation has not yet been applied on living
man, for the amputation of the thigh at the articulation. The two varieties
that it presents, were tried upon the dead subject, by MM. Cornuau and
Scoutetten first, and afterwards by all the young surgeons who practised the
manual of operations in the amphitheatres.
252 NEW ELEMENTS OF
1. Process of M, Cornuau.—The patient is laid upon the healthy side. The
surgeon, placed behind the hip, makes the firSt oblique incision, which com-
mences above the great trochanter, and must be carried from behind outward,
and downward to below the ischium; makes another similar incision before
and inward; then a second cut for each incision, to divide the muscles as
deeply as possible ; he then attacks the articulation at its external face at the
same time that the member is abducted by an assistant : passes through the
articulation inwardly as soon as the head of the femur is dislocated. In fine,
whilst a second assistant raises the two flaps, he divides the interosseous liga-
ment, the inner part of the capsule, and all the soft parts tbiit separate the
inner extremities of the two first incisions, or form the base of the V.
2. Process of M. Scoutetten. — The operator first sinks the point of the knife
above the great trochanter ; then depresses the handle gradually, to divide
all the tissues as before ; commences again at the posterior extremity of the
first incision, and passes over the other side of the member, to unite it with
the summit of the first. If there remain any soft parts between the internal
posterior part of the neck of the femur and the integuments, the operator
divides them, and finishes by disarticulation.
§ 2. Relative Value of the Various Methods.
Of these numerous methods, I can only repeat what I have said of the ampu-
tation of the shoulder. Almost all are applicabl e in practice. No one should be
exclusively adopted. Yet as many of them are mere modifications of others,
they may be rejected without inconvenience. In the circular method, for
instance, which is certainly the least advantageous, and which should be se-
lected only in case the disorganization of the integuments extends over every
part of the circumference of the member to very near the hip, Abernethy's
method, and that of Graefe, differ only in this, that that of the German surgeon
admits of a more easy reunion of the lips of the wound than the other. The
modification of Mr. Weitch has no other value than as it permits the operator
to remove the fractured member first, and then to proceed with the disarticu-
lation of the superior fragment by another incision. A precaution that I
would not fail to take would be, to dissect and evert carefully all the healthy
skin, in order to divide the muscles very high, and to remove as much of them
as possible.
The oval operation is appropriate wherever that of the double flap seems
applicable. It makes a wound almost as regular as the circular, presents no
obstacle to immediate reunion, and exactly tills the cotyloid cavity. Of the
two aspects that it has been made to present, one has scarcely any advantage
over the other. I would only recommend that the cutaneous envelope should
be divided lower, and the muscles higher than has been prescribed. The
bringing together of the lips of the wound will be thus rendered more easy,
whilst the inflammation, reaction, and suppuration, will manifest themselves
with less intensity.
Among the flap operations, the double ones are somewhat indispensable,
when it is possible to give them the same length, and when the soft parts are
equally altered in all directions. Then Dupuytren and Guthrie-s are superior
to the others, because they permit us to save more skin than muscle ; and also
because the flap, being placed obliquely and not on each side, as in Blandin's,
OPERATIVE STTRGERY. QS$
Larrey's and Lisfranc's, more easily fill up the cavity formerly filled by
the head and neck of the femur with the great trochanter.
When an external flap is formed after the manner of Larrey, it is rare that
it does not present a slope on its inferior edge, or that it corresponds in thick-
ness with the internal one.
The single flap operation should be preferred, if the soft parts of one side
be diseased when those of the other side are not. In such case the nature of
the disease indicates in what direction to preserve the flap, which should not
be outside nor behind if it can be avoided. Inwards and anteriorly I prefer
Lalouette's to Delpech's method, and still more one of the modifications re-
cently proposed. As M. Lenoir performs it, Lalouette's method gives a flap
much more regular than that of the professor of Montpeliers ; but this flap is
too thick, and not sufficiently large. By cutting from the exterior inwardly,
as Mr. Ashmead does, the operator is more sure of what he does ; the ligature
of the artery may be neglected, and he saves more of the integuments than
of the muscles. It was thus that I operated on the patient of whom I have
spoken. After raising the skin for three inches before and within, and making
a semicircular incision outwards above the great trochanter, I went on to the
division of the flesh and the disarticulation from the front, without stopping
for the artery, which an assistant compressed upon the crest of the pubis : the
(^eration occupied but half a minute. The previous tying of the femoral
artery, recommended by Lefebure, Moublet, M. A. Blandin, and M. Brula-
tor, adopted by MM. Larrey, Delpech, Orthon, and Roux, and rejected
by Abernethy, Baffos, Guthrie, &c., is, as has been said, one operation more
added to the primary one ; yet if in the flap operation, compression over the
pubis or with the fingers in the flap, as it may be effected, in executing the
method of Lalouette, Lisfranc, or Delpech, and even the oval method, should
not give all the security desirable, it is so easy to discover the femoral artery
under Poupart's ligament, that it is best to do so, unless it be thought prefer-
able to adopt the proposition of Mr. Ashmead.
Unless the patient be very weak, or the operation occupy considerable time,
I cannot see the necessity, or even the utility of tying the arteries before dis-
articulation. The fingers of a skillful assistant appliecf upon these as they are
divided, permit us, as I have satisfied myself, to wait until after the removal
of the limb. These arteries are, the obturator within, the ischiatic without and
behind, then before and without, some branches of the gluteal or of the
internal pudic : it is also necessary, even if the ligature should have been
applied before the operation, to again tie the femoral artery at the bleeding
surface, as well as the deep-seated muscular, in order to produce immediate
union of the little wound which had been first made.
The necessity of bringing in contact as much as possible the two sides of
the enormous wound which is left by the disarticulation of the thigh, is not
contested by any person. The suppuration of so large a surface would soon
destroy the patient, from exhaustion, and would never fail of being attended
with the most violent general reaction. The suture, which M. Delpech much
applauds, has been often applied, and it must be confessed that it is one of the
cases in which its employment seems most justifiable. It is not to be applied
without pain, it is true ; but if it be useful, should a little more or less suffering
be allowed to rob us of its advantages ? I would remark, however, that it is
m
NEW ELEMENTS OF
not the integuments, but the deeper tissues that it is so especially important
to bring together; and that by using the suture, it is to be feared that the
matter formed, if it accumulate at the bottom of the wound, may produce
serious injury before it can escape. The adhesive plasters, which have the
advantage of not impeding the discharge, also permit us after some days to
approximate the edges of the wound more exactly than at first, if the base of
the flaps appear to unite properly. Without absolutely rejecting the suture,
which seems to be jrainino- favor at this time in the south of France, I believe
that we may, and that we should dispense with it in this operation except in
some particular cases, which the intelligent surgeon will always be able to
distinguish.
TITLE III.— EXCISION OF THE BONES.
Practised from the time of Galen for certain bones of the trunk, and to all
appearance for some of the articular heads, excision of the bone has only been
used, according to fixed rules, for about half a century. It is performed in the
continuity, or at the extremity of the bone, and is always used to avoid ampu-
tation of the limb.
CHAPTER I.
In the Continuity.
In the continuity of the bone excision is rendered necessary, either by
recent complicated fractures, old fractures not consolidated, caries, necrosis,
osteo-sarcoma, spina-ventosa, or by any other incurable organic disease.
1st. Recent Fractures, — When in a fracture the extremity of one of the
fragments escapes and projects through the torn integuments, if suitable
extension of the opening and well-directed efforts fail to replace the parts, the
excision of the projecting portion of the bone has been always recommended
and practised. The operation is very simple. Two assistants lay hold,
one of the upper, the other of the lower portion of the limb, to increase its
curvature, and make the osseous points project still more. The operator
extends the wound if necessary, protects the flesh by means of a fold of linen
or a piece of pasteboard, aiid divides the denuded bone, either with an ordi-
nary saw, or some instrument appropriate to the form and position of the part.
It is to the tibia, fibula, the bones of the fore-arm, and some of the phalanges
OPERATIVE SURGERY. Q55
that this kind of excision has been most frequently applied ; the principles of
which it is almost impossible to lay down.
2(1. Wounds from Fire-arms. — In the sequence of wounds by fire-arms,
when the principal bone or bones of the member have been fractured and
reduced to splinters, whilst the soft parts adjoining have not been too much
injured, instead of amputating, it was early thought an advisable course to
extract the detached bony pieces, and then to project the angular fragments
of the two ends of the bone for excision. In this case the surgeon is almost
always forced to augment the original wound, or even to make a new one.
The tissues are commonly divided in the direction of th.e axis of the limb, at
some point distant from the vessels and nerves. By this incision the two
ends of the bone are made successively to escape. After having isolated
them properly, the surgeon dissects away the points and all the parts that may
affect the cure ; and conducts himself otherwise as in the preceding case.
3. Old Non- consolidated Fractures. — After certain fractures consolidation
does not take place. The two ends become rounded , and form in the continuity
of the member an abnormal fracture, that injures or almost entirely destroys
its functions. To remedy this accident, some authors have proposed the injunc-
tion of perfect rest, and the employment of certain machines for a long time.
Others have thought it better to pass a seton through this species of morbid
articulation. Some content themselves with rubbing the osseous fragments
against each other to produce inflammation. M. Somme has recently passed a
silver wire around the intermediary substance, to produce an insensible divi-
sion of it. M. Harsthrom has not been less successful in destroying it, by apply-
ing caustic potass upon the two extremities of the fragments. But in such
cases rescission is a means that offers evidently more chances of success.
White, of Manchester, who attempted it once in 1760, for a non-consolidated
fracture of the humerus, the two extremities of which he sawed after having
brought them out, and at another time on the tibia, cutting off only the supe-
rior fragment, completely cured both subjects. M. Viguerie and Langenbeck
imitated him with the same happy results, for fractures of the fore-arm. M
Dupuytren, who from choice only excises the upper portion, contents himself
with rasping the other. M. Rowlans, M. Pezerat, &c., have also performed
this resection with success, for non-consolidated fractures of the thigh. Messrs
Larrey, Boyer, Richerand, Physic, &c. cite some cases, which were followed
by serious accidents, and even death. So that it should not be decided
upon until after mature reflection, and after its necessity is well esta-
blished ; the more so as the disease sometimes becomes a supportable infirmity.
An example is found in a thesis of M. Carron of a man labouring under one
of these fractures of the thigh, and who walked very well without crutches. In
a case of M. Kulnholtz there was a complete false articulation, which scarcely
affected the functions of the limb. M. Cloquet speaks of a patient in whom
the superior fourth of the humerus had been for a long time destroyed, without
preventing the movements of the arm. M. Yvan-says the same of the femur.
The double gutter of tin, contrived by the artist Baillif, enabled the three
individuals mentioned by Trochel to walk with ease. I have myself seen at
the central bureau, a woman who had one of these fractures of the right
thigh, and who travelled \dthout crutches by the aidof a very coarse machine.
The Method of Operating is, as to the rest, nearly the same as for fractures
256 NEW ELEMENTS OF
with external laceration ; presenting only this diiFerence, that the division of
the tissues must always be made at the point most favorable to the eversion
of the end of the bone, and where it will cause the least danger, whilst in
the other case it is frequently sufficient to prolong more or less the existing
opening in this or that direction, and in a way which it is here unnecessary to
indicate. The two fragments are made to present, one after the other, at the
incision ; when, after detaching the adhesions and protecting the flesh and skin,
division is made of the non-consolidated ends of the bone.
Whether the excision has been performed for a recent fracture, with or
without displacement, or for an ancient fracture, the subsequent treatment
and dressings are in both cases nearly the same. In every case the limb must
be restored to its natural shape, the bone sunk into its place again, and retained
there after the reduction. The incision should be filled with charpie or lint,
and if necessary covered with a perforated bandage. If it appear possible to
escape suppuration, immediate union should be attempted by the assistance of
some pieces of agaric and graduated compresses, or by the suture and appro-
priate dressings. The whole is to be maintained by Scultet's bandage,
cushions filled with straw, or even splints, when it is not possible to prevent
movement of the limb without them.
Organic Lesions. — Excision for caries, necrosis, &c. although less frequently
practised than that of which we have just spoken, is nevertheless very often
indicated. Except the observations of Tenon, who did not hesitate to remove
the great trochanter; those of Moreau, who, in 1793, excised a considerable
portion of the tibia; of Percy and Laurent, who are said to have removed
eight or ten inches of this bone with the saw and trepan, and to have removed
the whole of the fibula for a caries, or rather, no doubt, for necrosis of the leg ;
of Beclard, who in conformity to the advice of Desault, dared also to excise
the superior third of the fibula for a spina-ventosa ; of Hey, who in his work
reports many cases of the excision of the bones of the leg and arm ; of M.
Couty de la Pommeraie, who has lately published a case of abscission of
almost the whole extent of the humerus, surgeons scarcely mention this kind
of operation, which, however, has been very recently practised at the Hopitaly
SeaujoUy with entire success for a very extended necrosis of the tibia. The
surgeon being obliged to conform to circumstances, to vary the operation in
accordance with the preservation or loss of the natural form of the member,
with the extent or seat of the disease, lays the bone bare by means of simple
longitudinal incisions, or when absolutely necessary, by making at the ex-
pense of the soft parts one or more flaps of suitable size and form. When
the disease is exposed, the saw or the trepan is to be applied, or in other cases
the gouge and mallet : the saw, when the bone is cylindrical or not voluminous ;
the trepan, when the bone is large and difficult to isolate, when very thick, or,
in fine, when the neighbouring parts will not permit the use of the saw ; the
chisel, when only some laminae, a part of the thickness of the affected bone,
are to be removed. Incisive nippers may also be used, or indeed any other
instrument tliat an intelligent operator may contrive. M. Seutin, of Bruxelles,
who with remarkable success extracted almost the entire fibula, used a tre-
pan to separate the superior extremity, and divided the lower with a curbed
saw. It is here that the flexible or chain saw, are particularly indicated.
Not only can the abscission of the central portion of the limbs be thus
OPERATIVE SURGERY. S57
eflfected, but it may also be practised upon the trunk, the cranium, the
sternum, the ribs, the clavicle, the vertebrae, &c.
ArLl,— 'The Ribs,
Among the excisions of the bones of the trunk, there is one that has more
especially fixed the attention of the moderns: I speak of the abscission of the
ribs, which is said to have been performed by Galen, Aymard, Sedillier, Lecat,
Ferrand, &c., and which the Indians are said to have often used, and to which
they gave a particular name. The old Journal JEncyclopedique, contains an
example, the knowledge of which I owe to M. Dezemesis. Suif excised two
ribs from a man named Botaque, so that he could pass his fist into the chest.
An affected portion of the lungs was removed , and the patient cured. Yet it
was scarcely thought of, when, in 1818, M. Richerand performed it upon a
person affected with cancer of the thorax. Since then it is known that Dr.
Celadini has performed it twice successfully in Italy. Percy and Laurent
are said to have tried it with like success, and recently the journals inform
us of its having been attempted at the Hopitcd Beaujon, at La Charite, and
in America, by Dr. Mott. M. Richerand's case is, without doubt, the most
remarkable of all. It was necessary to remove the central portion of four ribs
for several inches in extent. The pleura, being much thickened, and having
passed into the lardaceous state, had to be also destroyed ; so that the pulsa-
tions of the heart were plainly seen, that organ being enveloped in the
pericardium. The result of this beautiful operation was at first most
satisfactory ; but after some months, and before the complete cicatrization
of the wound, the cancer again appeared, and terminated the existence of the
patient.
Operation. — After exposing the rib or ribs to be excised, after having
extended the incisions as far as the disease in each direction, either a saw in
the form of a cock's comb, or the chisel and mallet, or simply that kind of
shears employed in the amphitheatres, known by the name of secateur, may be
used, commencing at one or the other end, and finishing at the opposite
extremity of the rib. It is necessary to preserv^e as much as possible of the
pleura, which all operators have remarked is then sensibly thickened. If,
however, it be too deeply affected, and especially if it be the seat of a cancerous
degeneration, it should be destroyed without hesitation.
,Srt, 2. — Sternum,
Galen had the boldness to lay bare the greater part of the sternum, and
isolate it by means of a trepan and gouge, and remove the whole diseased
portion, so as, like Richerand, to expose the heart to the eyes of the assistants.
The same course must be pursued at the present time, when it has been
decided upon to follow the precepts of the physician of Pergamos ; a course
that has been followed in the last century by Sedillier de Laval.
The excision of the crest of the ileum* attempted by Leaulte; that of the
OS calcis, two cases of which are reported by Hey and Roux, and which I have
myself performed ; of the spinous processes of the vertebrae, which M. Jules
Cloquet recommends, and which Dr. A. G. Smith used with success on a
33
258 NEW ELEMENTS OP
patient laboring under paraplegia for two years ; of every bone, in fine, that
naturally projects beneath the skin, cannot be a very difficult nor even
delicate operation ; but as the form of the disease and its extent always pro-
duces great modifications in the operation, I cannot enter into more lengthened
details upon the subject.
Art, 3. — Lower Inferior Jaw,
History and Value. — Wounds from fire-arms, accompanied by comminuted
fracture, have long proved that considerable portions of the lower jaw may
be destroyed without producing death. Caries and necrosis have also often
caused the destruction of this bone ; and yet those thus affected have com-
monly recovered, even without any very great deformity. Hippocrates gives
an example. One of the most remarkable was that observed by Guernery; the
jaw entirely exfoliated, but was so far reproduced as to permit mastication !
V. Wy speaks of a patient who lost the whole, either spontaneously or by
the aid of art. Two such cases are met with in Desault's journal. Chopart
and Louis have also extracted it successfully. Walker says he was obliged
to remove the two branches and a part of the body in a negro, who afterwards
recovered the power of masticating. A woman, observed at Bourges by Rug-
g;er, had lost the right half. Boyer reports, in the Bibliotheque de Flanque^
the case of a patient who had it earned away by a mill-wheel, and recovered.
Wepfer cites a case in which the amputation of the side of the jaw had been suc-
cessfully made in his time. In fine, M. Larrey speaks of a soldier who liad had
the jaw almost entirely destroyed by a gun-shot, but who still lives. In fact,
many subjects may be seen at the Invalides with traces of similar mutilations.
Yet observations of this kind remained without application, when in 1812,
M. Dupuytren resolved to amputate almost the whole body of a cancerous lower
jaw by a new method, to which the title of a surgical triumph has been given.
Since then the same operation has been repeated a great number of times by
the same professor; and also in Germany, England, America, and France, by
Mott,Richerand,LaUemand, Delpech,Roux,Casack, Martin, Gerdy, Magen-
die, Cloquet, Wardrop, Lisfranc, Warren, Gensoul, Grsefe, Walther, Wagner,
Randolph, and myself. It is not only to necrosis that it may be applied,
but also, and especially to cancers and all organic affections that will not
yield to any thing else than the removal of the parts that are their seat. If
it should appear to make success doubtful to go beyond the first molar teeth,
because the attachments of the genio-glossus and geneo-hyoideus, of the mylo-
hyoideus and digastricus muscles being destroyed, the tongue, acted upon by
the glosso-pharyngeus, must be apparently drawn back and fill the pharynx,
and thereby endanger suffocation, it should be known that experience has
confirmed these fears only in part. M. Dupuytren has gone beyond the first
molar teeth. In M. Richerand's patient, the whole body of the bone was re-
moved. I have twice performed this operation, and each time went to the canine
teeth. After the dressing no precaution was taken to fix the tongue anteriorly,
and yet there resulted no unpleasant symptom. M. Walther and M. Graefe,
according to Dr.Pattison, then Dr. M'Clellan, have removed almost the whole
bone, and cured their patients. If the disease be situated more on one side
than on the other, then it is possible to leave untouched the opposite half of
OPERATIVE SURGERY. 259
the organ, removing only that which is altered. It was thus that Mott, J. Clo-
quet, Lisfranc, Blanchet, Roux, &c., did ; in this case the inconvenience in
question is not at all to be apprehended.
It is certain, on the contrary, that in other cases the tongue is carried with
great force backwards and upwards, as soon as its an^terior attachments are
divided. M. Dupuytren always warned his auditors of this, and M. Delpech,
who made it the subject of some interesting remarks, even thought of remedy-
ing it, by passing a golden wire through the organ near the frasnum, for the
purpose of fixing it to the teeth nearest to the extremity of the remaining frag-
ments of the bone.
Operation,
A. Body of the Jaw. — When the disease is confined to the chin, the
operation is generally very easy and simple. In this case there are two
methods of operating. If all the soft parts are healthy, they are divided upon
the median line from above downward, from the free edge of the lip to the
thyroid cartilage, and the two flaps, thus formed, dissected and everted. In the
other case, two incisions uniting over the larynx, should form a V, or triangle,
comprising within its limits the whole disease.
The apparatus consists in needles, ligatures as for hare-lip, a chafing-dish
of fire, cauteries, and all other things necessary in amputation and dissections
of the most delicate nature. Three assistants at least are necessary.
First Stej). — The patient maybe seated on a chair or a bed, moderately
elevated. An assistant placed behind, turns back the head with one hand,
and lays hold of the angle or right side of the lip with the other, at the moment
the surgeon commences the incision. The latter, with the first two fingers of
the left hand, takes hold of the edge of the lip on the other side, whilst with
the right hand armed with a bistoury, he makes the incision ; and then suc-
cessively dissects away the two sides of the wound as far as may be necessary
around the disease, taking care to commence with the right side. Having
done this, he separates the muscles and other soft parts that adhere to the
edges and internal face of the bone, carefully avoiding the insertion of the
genio-glossal muscles. The operator may, as some person recommends,
reserve this part of the operation for the end, and saw the bone before dis-
secting it away. An ordinary saw will serve the purpose. A tooth on each
side of the confines of the disease should be removed, if they have not already
fallen out, and if they seem likely to interfere with the action of the instru-
ment. The operator, holding with one hand the anterior portion of the
affected mass, applies the thumb a little behind it upon the healthy portion of
the bone (which should also be fixed behind at the angle by an assistant), in
order to direct the action of the saw, which should pass as nearly as possible
between two alveoli and from above downward, or vice versa, as it may be
most convenient. This first division having been accomplished, the assistant
takes hold of the diseased tissues, whilst the surgeon passes his hand behind
them. A second passage of the saw terminates the section of the bone, which
in order to be removed must be depressed; whilst the other assistants,
separate, retract, and protect carefully the soft parts of the neck and face.
It then rem.ains only to detach the deceased fragment from the tissues within
the mouth, by carrying a bistoury flatwise, and vertically upon the posterior face
260 NEW ELEMENTS OF
of the chin. At the same instant, an assistant having the hand covered with
a piece of linen, seizes the tongue by its point and draws it outward, thus
preventing the symptoms of suffocation, and permitting the surgeon to pass a
cautery, heated to whiteness, over the whole extent of the wound, or at least
wherever any arterial branch is likely to be found.
With two or three points of twisted suture the two lips of the wound may
be united, the inferior angle of which, however, should remain open, and even
filled with a tent, to allow free passage to the results of suppuration. Some
strips of diachylon, some pledgets and compresses, and a bandage, complete
the dressing. Some persons place several small pledgets of coarse charpie
behind the tissues of the face, in order to fill up the vacuum between the two
bony fragments.
Remarks. — When the loss of substance is not considerable, it is well to
bring the fragments in contact, and fix them so by means of a wire passed around
the anterior teeth, as M. Delpech has done. In the contrary case, this pre-
caution will be at least useless. The ligature through the inferior face of the
tongue, recommended by the professor of Montpelier, will only be necessary if
this organ continues to be violently retracted towards the throat. Some persons
find the bandage superfluous, and content themselves with the suture and
compresses; the latter method gives the parts more freedom, and permits
the surgeon constantly to watch the progress of the pathological phenomena.
But this must all be left to the taste of the surgeon.
The sub-mental, sub -lingual, very rarely the ranine, the terminating branch
of the inferior maxillary, and the coronary arteries of the lip, are almost the
only vessels that the instrument encounters, and that require attention.
Some of them, hid in the soft parts, are too difiicult to find to admit of
the ligature. It might be possible with cold water, or sponges soaked in
vinegar, to arrest their bleeding, and thereby dispense with the heated iron.
Yet, as M. Dupuytren uses the latter means constantly with success, prudence
at least, if not necessity, justifies its application. The three last named
arteries cease to bleed spontaneously, and scarcely ever require particular
attention. In one case M. Graefe had a hemorrhage from the central artery
of the bone. In this case a plug of wood or wax, like that which M. Magendie
used, or a compress of any kind, at the point from which the blood escapes,
should be employed, if the operator do not prefer to have recourse to the
cautery. Lastly, instead of a simple incision, or two incisions united at their
inferior extremities, it may be necessary, if the disease be extensive, to divide
each lip of the incision transversly below the lower edge of the jaw.
B. One of the Branches of the Jaw, — When the amputation need com-
prehend only one of the sides of the inferior maxillary bone, the operation is
not altogether the same as that just described.
1. M. J. Cloquet began with the vertical incision above described; then
made a second, extending from the commissure of the lips to a point above
and behind the angle of the jaw; then dissected and turned outward and
downward the very large flap of the soft parts thus described ; detached the
tongue from the internal edge of the alveolar process, and ended with the
section of the bone ; cutting first anteriorly and then posteriorly at the origin
of its ascending plate.
2. Dr. Mott operated in a manner a little different. He began by tying
OPERATIVE SURGERY. 261
the carotid artery of the diseased side, and then proceeded to the amputation
of the bone. The first incision began at the ear on a line with the condyle,
and extended in a semilunar form with its convexity backwards to near the chin,
and below the labial commissure. The teguments, the inferior part of the
masseter muscle, and the parotid gland, were then dissected away. A second
incision, from the superior extremity of the first toward the anterior edge of the
sterno-mastoideus muscle, passing below the ear, enabled the surgeon to expose
the whole diseased part. With the aid of a small saw the jaw could be divided
anteriorly on a line with one of the lateral incisor teeth. With another saw,
smaller than the first, and made expressly for the case. Dr. Mott made a section
of the ramus of the jaw immediately below its two upper apophyses, and was
not able to remove the whole morbid mass, until after having carefully de-
tached it from the internal pterygoid and mylo-hyoid muscles. In the latter
part of the operation he properly directs the complete division of the inferior
maxillary nerve, before exerting any traction upon the bone, and that it should
not be forgotten that the lingual branch of the fifth pair is found in the neigh-
borhood.
Remarks. — W^henever one of the sides of the jaw is amputated instead of the
chin, the facial artery is necessarily divided at a greater or less distance trom
its termination. In M. J. Cloquet's operation it was divided at the time of
the transverse incision, and again whilst detaching the flap ; but the latter
section may be, if necessary, avoided. By Dr. Mott's method we wound it
inevitably whilst passing over the external face of the bone. When the aflfec-
tion does not reach beyond the maxillary angle, it is evident tli at the method of
the French surgeon merits the preference. When, on tlie contrary, the alteration
reaches very high up towards the temporo -maxillary articulation, by imitating
the American professor we are more sure of exposing the whole disease, whilst
at the same time we preserve the parotid gland and its duct. His method is
equally adapted to disarticulation, if it should be preferable or necessary, as
with the patient operated upon by M. Gensoul, and who died of a pleurisy
the fourteenth day. Upon the whole each case must have its peculiar
exigencies. It is for the surgeon to select or originate the most appropriate
method, when any other than the middle part of the bone is to be amputated.
The preparatory tying of the carotid, performed by Mott, Cusack, Walther,
Graefe, and Gensoul, can be indispensable only in a small number of cases,
and in them it must be because the saw acts transversely, as, for instance, very
near the temporo -maxillary articulation ; yet it is probable that even then
it will often be possible to dispense with it. The temporal artery (opened
once in England), the internal maxillary, the external carotid, and the inferior
dental, which lie along or turn around the posterior edge and neck of the con-
dyle, or are found within the maxillary branch, can be easily separated by a
well-taught assistant, at the moment when, after having sawn the bone, the
operator wishes to detach it behind from the tissues that adhere to its internal
face. A ligature applied to tliem after the dissection, would also be another re-
source against any unhappy result, and the compression of the primitive ca-
rotid is too easy to leave room for any very great inquietude. When the tis-
sues of the face are healthy, perhaps it would be better to imitate M. Roux in
forming a large flap with a downward convexity, which may be dissected and
everted from below upwards.
562 NEW ELEMENTS OP
After filling the space that separates the two ends of the bone, with charpie,
a^ariq, or sponge, the lips of the wound is to be united by the necessary
number of needles and hare-lip sutures, as after amputating the chin.
Jifter the Operation, — At the first annunciation of this operation, it was
thought there would result from it a very great deformity, and an impossibility
of executing mastication. It was a mistake. In the case of Lesier, tlie first
patient operated upon b}^ M. Dupuytren, almost the wliole body of the bone
was taken away, yet the loss is now scarcely perceptible. Others, since ope-
rated upon, are almost in the same situation, without excepting even M.
Ehrmann, of Strasburg. Cellular matter soon shoots up between the bony
fragments, becoming fibrous or cartilaginous, and ultimately acquiring so much
solidity as almost to equal the bone that it replaces, the two remaining portions
of which it firmly connects.
But it must be stated that M. Lallemand's patient was not so fortunate. In
him the two ends of the bone remained movable, on which account he is obliged
to use an artificial chin. But the loss of substance had been very considerable ;
wliich explains at the same time the danger caused at first by the retreat of
the tongue — a danger at once removed by instantly performing tracheotomy.
The wound may remain fistulous at its inferior angle, because of the passage
of the saliva through it, and thereby cause the exhaustion of the patient.
One of those I have operated upon was in tliis condition, when erysipelas
carried him off the twenty-second day after the operation. I saw, in a case
operated upon by M. Richerand, the tongue so much drawn back as not to
permit the ingestion of aliments. Death occurred on the twenty-eighth
day, and seemed the consequence of suffocation. Perhaps it was the same
with the woman operated upon by Magendie, in 1830, at La vSalpetriere, who
died suddenly in the night. After the removal of one of the lateral portions
of the jaw, the fixed point of the genio-glossal muscle being preserved, there
is less danger of retraction of the tongue. In this case an obliquity in the
projection of the chin, sometimes very decided, is almost inevitable. It took
place in the patient operated upon at the Hopital de Perfeciionnementy in 1826,
and was also observed in the cases cited by Mott, Gensoul, Lisfranc, &c..
To conclude, the amputation of the chin is a happy acquisition to modern
surgery, and that of one of the sides of the bone, even when it is necessary
to comprehend the articulation, appears to be an equally valuable resource in
many cases ; but it is difficult to comprehend how the entire removal of the
whole bone can be successful in curing the disea'se, and yet preserve the
faculty of deglutition. We know that as a consequence of its exfoliation, of
which Snell, Gambini, and Bellemain, have reported some new examples, it
may be otherwise. The dead part is not separated until the system has more
or less completely prepared itself for its absence by the creation of a new
tissue, that lessens very much the deformity. It is also known that the forcible
extraction of the exfoliation, performed by M. Dupuytren, in 1830, is nothing
else than an amputation properly so called, and that there can be no method
given for the performance of this operation,
Art, A. -^-Superior Maxillary Bone,
Encouraged by these successful cases, by some examples of the destruction
of the sinus and some serious lesions of the superior jaw-bone, spontaneously
OPERATIVE SURGERY. 265
cured, M. Dupuytren immediately thought that the abscission of this bone
might also be attempted. It besides appeared, that Acoluthus had performed
it in 1693, for a tumor of the face, and cured his patient. Camper speaks of
a subject who had lost the entire bone, and yet survived. Still, however,
Bidloo and Desault, who had conceived the possibility of the operation, had
gone only so far as to recommend it. These vague and unfixed notions it is
evident detract nothing from the moderns in this question ; a question which
in itself really comprehends two — the excision and the disarticulation of the
bone. M. Paillard affirms, and the bulletins of the faculty prove, that M.
Dupuytren had recourse to the first of these operations, in 1819, and to the
second, in 1824. M. Pillet, who insists that M. Gensoul is the only person
who has yet performed the latter, says that the patient of M. Dupuytren,
having died at La Salpetriere, it was found that a portion of the bone had been
left.
It was in 1 826 that M. Lizars, who also claims the priority, proposed it ; he
performed it in 1 827, 28, and 30, with success. But it appears to me tliat all'
pai'ties think too highly of the importance of this part of the question. The
excision of some portions of the superior maxillary bone has been long ago
performed; at the present time some have gone a little further: this is the
whole affair. Even when tlie whole of the bone has been removed, a thing
not easy to prove, the circumstance does not merit the title of an invention.
This debate then is not w^ori h the pains that have been bestowed upon it. M.
Dupuytren has in certain cases made the excision of the alveolar edge by
means of nippers or cutting forceps, or the chisel and mallet ; in other cases
he has made incisions on the face, in order to remove the osteo-sarcoma more
surely, and many of his patients thus treated have done very well. M. Gen-
soul's case, it is said, has completely recovered ; although, as M. Pillet says,
the palate bone itself was entirely extracted. Mr. Lyme, who attempted it in
the early part of 1829, for cancerous tumor of considerable size, made a cru-
cial incision, one of the branches of which extended to the corresponding
commissure of the lips, dissected and everted the flaps, and destroyed the
tumor by means of a cock's-comb saw, a chisel, and a very strong scalpel.
Some months after, the appearance of some vegetations awakened apprehen-
sions of a reappearance of the disease. The three instances of success, which
occurred to M. Lizars, having been obtained with different diseases, and by
different processes, cannot serve for the foundation of any particular metiiod.
M. Gensoul says, that although he removed the maxillary, malar, and palatine
bones four times ; that although he has four times extracted, and many times
excised the first named bone ; and that altli^ough in one case he took away
the pterygoid apophysis itself to its base, he has been always successful, and
always cured his patient. But as he does no^ give us the process he followed,
I am forced to pass over his experience in silence. M. Lisfranc exposed a
facial tumor by means of an incision in form of a V ; divided the naso-pala-
tine partition with the large scissors of M. (polombat, and finished with the
chisel and mallet. In 1823, Dr. A. H. Stevenjs used, in a similar case, a flexible
saw, passed by puncture through the bone ; and Dr. Rogers, of New York,
who, in 1824, removed the bone on each sicjle as far as the pterygoid apophy-
sis, had scarcely any occasion to divide the: lip. It is also necessary to add
to the other exam.ple that mentioned by M. Piedagnel, as occurring during
264 NEW ELEMENTS OF
the service of M. Bauchine, in 1818, and that which M. Lafont has just com-
municated to the academy.
I have also had occasion to practise the excision of the upper jaw upon a
female, aged forty-five years. AH the molar teeth of the left side had been
destroyed or extracted. An opening capable of receiving the end of the
finger, permitted me to explore with ease the interior of the sinus, the surface
of which was covered with bleeding vegetations. Its edges, equally fungous,
were hard and lardaceous, and blended with the surrounding tissues. Many
portions of the exfoliated bone belonging to its external and anterior walls,
were seen in the midst of the diseased mass, which extended backwards to the
palatine arch, and forward to the incisor teeth, and inwards to the median
line. The operation was performed early in July, 1829, at the hospital Saint
Antoine. One incision commenced at the commissure of the lips, and being car-
ried obliquely upward, outward, and backward, to the temporal fossa, between
the external angle of the eye and the pavilion of the ear, enabled me to avoid
the parotid duct, and after dissection to raise up a triangular flap, comprising
all the soft parts that covered the cheek bone and the canine fossa. With a saw,
applied immediately below the orbit, I divided the projectingpart of the malar
bone, and penetrated into the sinus ; with a very strong scalpel I then cut the
maxillary bone in front, after extracting one of the incisor teeth, so as to unite
the second section with the first ; at a third stroke I prolonged the incision of the
hard parts to the molar tuberosity. All the lardaceous tissue, a great part of the
necrosed bon6, and the whole facial walls of the sinus, were thus cut away.
With the point of the same instrument, I divided, through the mouth, a hori-
zontal portion of the palatine arch, parallel to the median line. I then scraped
the floor of the orbit, and made use of the dissecting forceps to extract many
scales that had been left, that belonged to the palate bone, the posterior walls
of the sinus, or the cavity of the orbit. It was necessary to penetrate in one
direction into the zygomatic fossa, and in another into the orbit. It was evi-
dent that the bone that separated these last two cavities had been destroyed;
for the finger, when carried to the bottom of the sore, pushed the eye upward
under the superior eye-lid.
Fearing tbat some of the diseased parts might have escaped me, I passed
the actual cautery over the whole extent of this large excavation. After filling
the wound with charpie, I united its lips by means of the twisted suture, sup-
ported by a simple bandage. The local and general symptoms, which were quite
serious for two days, were soon dissipated. The fifth day the mouth looked
well, and I removed the two last sutures. The suppuration ceased to be
fetid about the eighth day. When I left the hospital, three weeks after, the
interior of the mouth was of a lively red, scarcely sensible, and in a fair way
to heal. I understand that this wgman returned to her village before the comple-
tion of the cure, and after some months the primitive affection reappeared.
In another patient, operated upon in the same hospital in 1830, and for
whom I only took away the left alveolar border, the cure, which was com-
pleted in twelve days, has since continued perfect.
It seems to me, that for a disease of one of the halves of the superior max-
illary bone, the method that I have just described will ordinarily be sufficient,
and that it is difficult to imagine one more simple or easy. The crucial inci-
sion, employed by Mr. Lyme is more liable to injure the duct of Steno, and does
• OPERATIVE SURGERY. 265
not more certainly expose the parts to be removed. The employment of a
small scoop has appeared to me especially useful, and may be of great assist-
ance. If the alveolar edges only be diseased, the cutting, forceps, or even the
small scoop that I use, enables us to remove tl^ whole affection without di-
viding the lips. In other cases we must, if it cannot be dispensed with, divide
the tissues on each side, following the oblique line that I have above indicated.
It is, however, one of those operations, the manual of which must in some
degree be accommodated to each particular case, and in which we should be
cautious not to bind ourselves down too rigidly to any set of rules.
The extraction of a simple exfoliatiori of the upper jaw, comprehending
even a great part of the bone, such as occurred to M. Roux, in 1829, like that
of the lower jaw, produces not near so great a deformity as amputation. A
new production almost always takes the place of the original, and in one sin-
gular case, observed by M. Krimer, the molar teeth tliemselves were repro-
duced.
CHAPTER II.
Excision of the Articulations.
History and Value. — Although there is not one of the articulations which at
the present day has not undergone excision, yet there are some of them on
which this operation has been more frequently practised than others. Asa
general rule it is better adapted to the thoracic than the pelvic members, and
with them in proportion to their distance from the trunk. Although of appa-
rently modern origin, excision of the articular heads was not unknown to the
ancients. Hippocrates speaks of it in the articulations of the foot and hand,
et in tibia ad malleolos, et in cubitu ad juncturam manus. It is evident, in
fact, that in their ignorance of hemostatic agents, they would use every ope-
ration that could relieve them from the necessity of amputating a member.
None of them, however, give the details of the method that they pursued, and
it is only since the time of White that it has been looked upon as a distinct
operation. Park, who wished to extend it to all the articulations, ultimately
lessened its importance very much. M. Moreau is in reality the first who
truly demonstrated its value. The dissertation of Wachter, published in
1809, being much more theoretical than practical, would have remaine'd un-
known, like that of Chaussier, if it had not been for the labors of Champion
and Roux, Jeffrey of Glasgow, Crampton of Dublin, and Lyme of Edinburgh,
who at last have succeeded in fixing public attention upon the subject. In
spite of the facts already known, the excision of diseased articulations is far
from being approved by all operator^. Compared with amputation, its advan-
tages and inconveniences are so nearly balanced, as in fact to justify hesitation.
Its manuel is delicate, painful, and commonly very long; presenting in some
cases numerous difficulties, and necessarily involving acute suffering. Although
34
366 NEW ELEMENTS OF
the diseased bone may be removed, some portion of altered tissues may be left-
The resulting wound is extended and irregular, and almost always becomes the
seat or source of profuse suppuration, of reabsorption, or dangerous phlebitis.
The cure, when it occurs, is often deferred for months, and sometimes even for
years. The limb remains more or less stiff, sometimes fixed, and commonly
drawn by the muscles in one direction or another, and is so deformed as to
be almost unfit for the performance of any of its functions. Amputation, which
is generally easy, prompt, and consequently less painful, at once relieves the
patient from the bone, and all the affected soft parts. When performed upon
the healthy tissues, it gives a clean incision, easy to unite, of less extent, less
disposed to suppurate, and less favorable to the development of phlebitis
and metastasis. The cure, more probable and prompt, is also more complete.
To these objections it may be answered, that it is in the power of the intel-
ligent surgeon to surmount the difficulties of the operation, and shorten its
duration ; to know whether he can or cannot remove the whole disease ; that
if the bone be removed, the neighboring tissues, however altered, most fre-
quently may be restored to their natural condition; that a fungous or lard-
aceous degeneration of the ligaments, cellular tissue, and skin, is not always
an obstacle to cure ; that as the principal arteries, veins, and nerves, are left
untouched, the operation must in reality have less influence on the rest of the
system than amputation, properly so called ; that some patients are cured
very promptly, as Mr. Lyme cites some who used the limb after a few weeks ;
that the new substance formed in place of the excised matter acquires
solidity enough to replace the articulation to a certain extent, and yet permit
voluntary movements ; that with the aid of splints and proper dressing all
unnatural deviation of the member may be prevented, whilst anchylosis may
be obviated by early and suitable movements of the parts \ in fine, that how-
ever deformed it may become, it will always be adapted more or less to a
great many uses, of which the patient would regret to be deprived : from all
of which it follows, as far as I am permitted to judge, that the mass of the advan-
tages of excision is more considerable than that of the inconveniences, and
that it deserves to be counted among the efficacious resources of surgery.
The apparatus should consist in the first place, of that which is adapted to
amputation ; so that, if any accidents or unforeseen circumstances presentthem-
selves at the moment of the operation, we may proceed at once to amputation
instead of excision : then some peculiar articles, for example, several strong
spatulas, a gouge, a leaden hammer and a chisel, some saws, cock's-comb,
circular, or semicircular form, a chain saw like that of Dr. Jeffrey's, or a saw
like that of M. Machell, or a flexible one, such as the American and English
surgeons often use ; finally, one or more thin flexible plates of wood, paste-
board, lead or other metal, or simply a straight many-folded compress, proper
to place. between the bone and soft parts. Besides these, there should be one
of Scultet's bandages, cushions, splints — a sort of fracture apparatus for the
dressing.
OPERATIVE SURGERY. 26f
SECTION I.
Thoracic Members.
Art.l.—TJie Hand.
If the anterior or posterior third of one of the last four metacarpal bones
should be diseased, that portion may be excised without the amputation of the
whole finger. Many surgeons had suggested, and even performed it at the
commencement of the present century; as is proved by several theses on th{.
subject. It is, however, to M. Troccon, that we owe its subjection to fixed
rules. Mr. Wardrop, who performed the operation on two of the metacarpal
bones, is not the only one who has used it on living man. The head of the
first phalanx of the thumb was thus successfully excised at the commence-
ment of this century, by M. Bobe. Mr. Evans reckons two similar cures, and
M. Roux has been not less successful upon some others of the metacarpal bones.
Operation. — This forms, in fact, but one of the steps of extraction, properly
so called, of the same piece of the skeleton. After dividing the teguments,
separating the extensor tendons, scraping the bone on each side to detach the
interosseous muscles, disarticulating the extremity which is to be removed,
there is nothing more to be done than to slip a strip of wood, pasteboard, or
the like, beneath its anterior face, and then divide it sloping or perpendicularly
with a small saw, such as Jeffrey's chain saw.
Art. 2.-^The Wrist.
Others, besides M. Roux, and M. Hublie, of Provins, have excised the car-
pal extremity of the fore-arm. According to MM. Bobe, and Moreau, it was
performed successfully nearly thirty years ago, by M. Clemot, of Rochefort,
on a subject whose radius and ulna were luxated, and projected considerably
through the soft parts. M. Hublie's attempt, which was completely successful,
belongs to the same class. There was a luxation of the hand, and a projec-
tion of the bone through a laceration of the integuments. The extensor and
flexor tendons were uninjured : the surgeon resolved, after properly isolating
them, to remove the exposed portions of the radius and ulna, and then return
the arm and hand to their natural position. After the cure, which occurred
without any serious intervening accident, the fingers could be moved with
almost as much facility as before the disaster. There should be no hesitation,
if the reduction of the luxated bone be impossible, or too difficult ; but there
is another sort of incision, the utility of which is not so well demonstrated: I
speak of that relating to some organic lesions of long standing, such as
caries or necrosis. These diseases are rarely so serious at the wrist as
to require amputation, without being attended with profound affection of the
carpus and surrounding soft parts. But supposing the thing should be ne-
cessary, there are two methods that may be followed, and which have bieen
tried.
Operation. — 1st Method. — An incision on the radial side of the fore-arm,
and another on the ulnar, extending from the root of the thumb and from the
last metacarpal bone to two or three inches above the styloid apophyses of
the radius and ulna, and a connexion of these incisions over the posterior face
268 NEW ELEMENTS OF
4)f the wrist by a transverse incision, permit us to dissect and evert a flap that
will expose the whole dorsal face of the articulation. The flesh in front
should then be detached from the bone, so as to eijable us to pass between it
and the latter a thin piece of flexible wood, lead, or pasteboard. The radius and
ulna are then to be divided with a saw, above the diseased spot. The pieces
are then successively separated with a bistoury from the carpus, with which
they are articulated. The wound is then to be closed by means of several
stitches. Light pressure will bring together the internal faces of the wound,
and it is not impossible for the extensor tendons to recover their power over
the fingers. In this manner the operation is very easily performed on the
dead subject, whilst the radial and ulnar arteries are easily avoided in detach-
ing the flesh from the anterior face of the wrist. But one of the advantages
of excision being the preservation to the hand of the most of its movements, it
is important to have a method which will leave untouched all the extensor
tendons.
2d. M. Dubled^s Method. — After having made an incision first on the inside
of the ulna, M. Dubled detaches the lips of it from the posterior and then the
anterior face of that bone ; draws then away from it ; divides the lateral liga-
ment ; abducts the hand ; isolates completely the head of the bone ; projects
it as far as possible ; detaches it from the radius ; passes between the two
bones a plate of wood or lead, and detaches the part affected with a saw. The
same process is followed for the external edge of the articulation ; and as the
ulna is already excised, it is then much more easy to turn the hand inward,
draw out the radius, and perform the excision. In this manner all the ten-
dons will be saved, and the consequences of the operation become evidently
more simple. In practising it upon the dead subject, it appears to me very
easy of execution ; but it is not certain that it will be the same on living
man, and on a deformed hand.
Moreau and Roux^s Method. — The operation adopted by Moreau, Roux, and
Lyme, without being much more complicated than that of M. Dubled, has the
advantage of rendering the incision of the heads of articulation very much
more simple. A transverse incision, which begins at the carpal extremity of
each lateral incision, and prolonged from eight to ten lines upon the dorsal
face of the wrist, circumscribes a small flap in the form of an L, over the pos-
terior region of the radius and ulna. Tliey are dissected and raised up one
after the other, commencing with that over the ulna. After separating, de-
taching, and isolating the tendons, a protecting compress should be passed be-
tween the two bones by means of a spatula, and brought out between the palmar
face of the ulna and the soft parts. An assistant immediately takes hold of
it, and draws the two extremities towards the radius, so as to press the soft
parts towards that bone. Then with a saw the surgeon makes the division of
the bone, which he then detaches from the carpus and radius, by means of
a bistoury. He then dissects the second flap with the numerous tendons and
the radial artery which present themselves on this side. To finish, he has
but to do the same on the radius as he has just done upon the ulna. Moreau's
patient, thus operated upon, was cured. But we cannot give a just estimate
of the value of the facts in the case, for the want of minuteness in the details.
5 am ignorant of the ultimate results of M. Roux's case.
OPERATIVE SURGERY. 269
^r(, S.^The Elbow,
The excision of the elbow was first performed with success by Wainmann,
who removed only the trochlea, or pulley of the humerus, for a luxation of the
elbow ; proposed by Park, of Liverpool, in 1781, as applicable to chronic dis-
eases ; practised on the living subject, in 1782, by Moreau ; shortly afterwards
by Percy, Binns, and many other military surgeons. It has been attempted
five times by M. Roux, once by Mr. Crampton, four times by Mr. Lyme,
once by Mr. Spence, and since their first attempt, MM. Moreau, father
and son, MM. Champion and Mazzoza, have reported three or four new ex-
amples of it ; so that at the present time we can enumerate nearly thirty
cases.
Operation. — Parleys Method. — Park thought it sufficient to make an incision
parallel to the axis of the limb, extending two or three inches above and be-
low the olecranon. Its lips being separated, he endeavored to divide the late-
ral ligaments and the tendon of the triceps, so as to luxate the extremity of
the bone backwards ; but finding it too difficult, he first excised the olecranon,
and then accomplished his object more easily. The first step of the operation
over, Park made section of the humerus upon a plate which he had placed be-
tween the anterior face of the bone and the flesh, about two inches above the ar-
ticulation. The sides of the division were brought together, and kept so by
means of small bandages. In his letter to Pott, the author agrees that this
method will not probably serve for a diseased and swelled articulation ; but
that in such a case he would add a transverse incision immediately above tl>e
joint ; dissect up the four flaps, the whole posterior face of the bone thus ex-
posed, and remove with the saw successively the lower head of the humerus
and the superior portion of the bones of the fore-arm. Such an operatiom.
should not be performed in any case, either in its simplicity or with the crucial
incision, although Mr. Lyme may have used it once successfully.
2. iW. Moreau' s Method. — Instead of cutting on the median line, M. Moreau
commences by dividing the whole thickness of the soft parts from bel^w
upwards, for two or three inches, beginning at the condyles, and following the
edge of the humerus. A third and transverse incision unites the first two
immediately above the olecranon, forming a quadrilateral flap, which is to be
dissected and turned up on the posterior face of the arm. With a bistoury
laid flat upon the anterior face of the humerus, the flesh is to be carefully
detached. Then, having put a flexible strip of wood in the place of the instru-
ment, the remainder of the operation is performed like that of Park. If the
extremity of the radius and ulna must be removed, it is sufficient to prolong
the lateral incision a little downward, and thus form a small flap belcfw, which»
being dissected, renders the section of the bones that it covered very easy.
3. M. DupuytrerCs Method. — The method of Moreau is stich that it is
worthy of being followed, as it has been by Roux and Lyme, at least in most
of their cases. Yet they found it necessary to modify it ip some respects.
;M. Dupuytren has shown that the ulnar nerve, which is almost necessarily
^Sacrificed, can and should be preserved. After forming the quadrilateral flap,
and exposing the superior extremity of the ulna, like Park, he begins by ex-
cising the olecranon ; then carefully incises the sheath that envelopes the ulnar
nerve behind the trochlea ; pushes this nervous cord inwards and before the
SrO NEW ELEMENTS Ot
articulation, where an assistant holds it with a curved sound, the handle of a
scalpel, or even the finger, until the extremity of the humerus is removed.
4. Process adopted hy the Author, — The patient must be placed on his belly,
or at least on the healtlij side. An assistant compresses the humeral artery,
and supports the soft parts of the arm. Another person holds the fore-arm
extended. The surgeon on the outside, and armed with a straight bistoury,
first makes an incision two inches long upon the external edge of the humerus,
commencing or ending over the epicondyles, and extending upward so as to
separate the anterior brachial muscle from the external portion of the triceps.
A second incision is then made upon the internal edge of the arm, the inferior
extremity of which should fall rather on the side of the olecranon than upon
the epitrochle, in order to avoid the ulnar nerve. After uniting these two
longitudinally by means of a third and transverse incision, which should divide
the tendon of the triceps, the flap is easily dissected and turned up. An
assistant then seizes this flap, and if the extremity of the fore-arm appears
sound, the surgeon proceeds to the excision of the humerus. Otherwise
the lateral incisions must be prolonged, and an inferior flap formed analogous
to the other. As soon as the ulnar nerve is exposed, it is isolated from the
attachments that fix it between the trochlea and olecranon ; and whilst the arm
is extended, it is carried behind the internal tuberosity of the humerus as above
described. Then the operator brings forward the undivided flesh, and slightly
flexes the arm; separates the fleshy fibres from the anterior face of the
bone with the point of the bistoury; makes use of the saw; takes hold of the
superior extremity of the bony fragment; separates the tissues from it that he
may turn it downward and backward; divides the anterior, the internal and
external lateral, and the posterior ligaments. If the excision of the radius
and ulna must also be performed, he detaches the anterior brachial and biceps
muscles below the disease, and then divides those two bones with the saw from
before backwards, or vice versa, according as the state of the parts may require,
or render convenient. It would also be better in this case not to disarticulate
the humerus, but pass at once to the excision of the radius and ulna, as Mr.
Lyme advises. If the bones of the fore-arm be perfectly sound, we can
scarcely conceive the utility of the extirpation of the olecranon. When they
are diseased, the operation becomes necessarily longer and more serious, and
seems to me to offer but little chance of success, if it is necessary to extirpate
below the bicipital tuberosity of the radius, because then the attachments of
the two principal flexor muscles of the fore-arm are destroyed. The brachial
artery, separated by a thick muscle from the humerus, is never difficult to
avoid. There is greater risk when it has descended to the fore-arm on a level
with its bifurcation. It is of great importance to divide the radius and ulna
above the insertion of the anterior brachial, and especially of the biceps
muscle. Yet Mr. Lyme seems to have extended the excision to below the
tendon of these muscles in some cases, in which, nevertheless, the use of the
hand was retained.
After you have removed the bone, tied the vessels if there be any that
require it, cleansed the wound, and satisfied yourself that there remains
nothing of the disease behind, the elbow is again extended, the flaps brought
together, united by two or three stitches, and in the same manner attached
OPERATIVE SURGERY. 271
to the anterior soft parts. Pledgets of lint, graduated compresses, a Scultet
bandage, pads, and two thin splints, keep the parts in contact, and the
whole limb in the most perfect rest. The excision of the elbow is a
minute, long, and extremely painful operation. It is rarely followed by im-
mediate reunion. It is very frequently followed by profuse suppuration.
One of M. Roux's cases continued nearly a year before complete recovery.
It can only be used where the skin and a part of the muscles remain sound, as
in simple caries or necrosis, or in a comminuted fracture of the articulation.
These circumstances have alarmed operators, and tended to render this ope-
ration more rare than would at first be imagined. Yet it has always been
successful with the surgeons of Bar. M. Roux also cured three cases.
His first patient, operated upon in 1819, was well of the operation, when he
died of phthisis. The second has established himself as scissors -grinder on
one of the bridges of Paris. The third, on whom I saw the operation per-
formed, has re-assumed her trade of mantua-maker. A hemorrhage rendered
the immediate amputation of the arm necessary in a fourth, who died three
days after. M. Mazzoza's case was successful. The patient of Mr. Crampton,
operated upon on the 2d of January, 1823, signed his own discharge the
29th of November following. Of the four operated upon, from the first of
October, 1828, to the first of October, 1830, by Mr. Lyme, two are dead. A
third had to submit to a subsequent amputation of the arm. Eleven have been
perfectly cured ; some by immediate reunion, others after a longer or shorter
time, and all preserved most of the movements of the limb. The patient of
Mr. Spence, treated, in 1830, was equally successful ; so that it is impos-
sible not now to admit excision of the elbow as one of the valuable re-
sources of surgery, notwithstanding the opinion of M. Larrey, and my
former preceptor, M. Gouraud, who will only adopt it in cases of com-
minuted fracture or luxation, with division of the integuments and projection;
of the bone. It is true that the removed parts cannot apparently be repro4
duced, as some persons at first believed, and that the articulation of the elbow
is ever after wanting. But in their places there sometimes forms a substance
sufficiently solid to serve as a fulcrum, upon which the muscles can flex and
extend the fore -arm. The patients once cured, can always use their hand,
and are certainly very happy to escape amputation — the only resource left if
excision must not or cannot be attempted.
If one of the condyles or the olecranon only be diseased, the operation musi;
be performed, as M. Moreau has once performed it successfully; namely,
make one of the lateral incisions above-mentioned; make a second for the ex-
tremity of the first across to the middle of the breadth of the arm and belov
the olecranon ; dissect and evert the triangular flap thus made, upw^ard and
towards the median line of the arm ; then, by means of a chisel or gouge, re-
move the part of the bone affected, and return the flap to its proper place
for immediate reunion.
^rt. A.— The Radius.
A necrosis, with fungous degeneration of the periosteum extending almost
throughout the whole extent of the fore -arm, gave me the idea, in 1826, of ex-
cising or removing the radius (this being the only part affected), instead of
271^ NEW ELEMENTS OF
amputating the arm ; but the patients preferred submitting to the latter ope-
ration. Upon the dead subject, it maj be done without difficulty, and with-
out destroying any tendon or muscle. The fore-arm is to be placed in a flexed
position. An incision, parallel to its axis, exposes first the external and an-
terior edge of the radius. The two lips of the wound are then separated from
its posterior and anterior faces, by means of a bistoury, to a point a little below
its middle portion, where it lies almost naked beneath the teguments. At
that point, the operator should endeavor to pass a grooved sound between its
ulnar edge and the flesh, to serve as a conductor to a flexible saw. He then
divides the bone from within outward by means of this latter instrument, and
then extracts the two fragments, one after the other, by dissecting them care-
fully from their free extremities towards their articulations. If the integu-
ments, being difficult to depress, oppose the introduction of the saw, there
is no objection to dividing them on each side of the lips for some lines. It is
now an operation which has received the sanction of experience. Dr. R. Butt,
of Virginia, having performed it upon a man, in 1825, with complete success.
Art. 5.--The Shoulder.
In the year 1740, a surgeon at Pezenas, named Thomas, made known a
case in which the head of the humerus, being in the state of necrosis, was
successfully extracted. A little later, Boucher, in his memoir upon gun-shot
wounds, demonstrated that the head of the humerus, reduced to splinters,
could be removed without much difficulty, and without a sacrifice of the
whole member. The same doctrine has since been supported by Percy, M.
Lai;rey, and almost all military surgeons. The theses of MM. Triad and
Legrand may be consulted on this subject. As to excision in the case in
which the head of the bone has been the seat of an organic lesion, requiring
its removal, it has been performed, first by White, David, Vigouroux ; then
by Moreau the father. Bent, Orred, Percy, Moreau the son, and also, it is said,
by Larre}^ Grosbois, Porret, C. Petit, Brulatour, Roux, Willaume, Bottin, &c.
It is known, from the testimony of Sabatier, that in 1789, a child presented
with its right hand to the academy of surgery the scapular extremity of the
Humerus of that side that had been taken from him by the surgeon-major of
the regiment de Berry. The method of operating must necessarily vary
according to the morbid state.
Operation. — 1st. TVhite^s Method. — When most of the surrounding tissues
are healthy, or when tlie bone is reduced to fragments, the operator may,
according to M. Larrey and M. Porret, be content with an incision parallel to
the fibres of the deltoid muscle, extending from the summit of the acromion
four or five inches down, and penetrating to the articulation, as in Pojet's
method for the removal of the shoulder, published in 1759. Then, seizing
the elbow. White used it to sway the humerus, and thus produce a luxation of
its head upwards through the soft parts. M. Larrey separates the lips of this
first incision, opens the capsule, and then divides, by means of a button-
headed bistoury conducted by the nnger, the tendons of the supra and infra
splnatus, subscapulars, and teres-minor muscles, so as to remove all difficulty
of turning out the head of the bone. In both cases when the operation has
reached this point, a thick c6mpress, or some protecting plate, is to be
OPERATIVE SURGERY. S75
placed between the neck of the bone and the teguments, so as to saw without
inconvenience.
2d. M. Moreav^s Method. — M. Moreau remarks, justly, that the simple
incision, recommended by White, and even when modified, as by M. Larrey,
must be insufficient in most cases. According to him, two incisions of four
inches in length parallel to the fibres of the deltoid, one on its anterior the
other its posterior border, and united below the summit of the acromion by a
transverse incision, would be infinitely superior ; thereby forming a trapezoid
flap, which should be dissected and turned down towards the insertion of the
deltoid. Then all the anterior portion of the joint will be exposed. Nothing
will be more easy than to divide the capsule, turn out the head as well as
the superior portion of the bone, and perform the excision. The flap, then
turned up in its place, should be secured above and at its sides, by a few
stitches.
^d. Manners Method. — M. Moreau's plan evidently renders the excision of
the humerus much more easy than White's ; but his large flap, which diff*ers
from the deltoid flap of la Faye only in being detached and turned downwards
instead of the reverse, renders immediate reunion difficult, and exposes
to fistulae, which should be avoided. This plan, therefore, should not be
wholly adopted. It would be better, if the surgeon desired to have a trape-
zoid flap, to follow the advice of Manne, i. e. make two lateral incisions, like
Moreau, unite them by their inferior extremity, dissect and raise the flap
from point to base, exactly as la Faye recommends for amputation of the arm
at this joint.
4. Sabatier^s Method. — Instead of taking so much care of the soft parts,
Sabatier formally advises us to circumscribe a portion, in form of a V, in the
midst of the deltoid muscles, and then to excise this triangle to expose the
naked capsule of the joint. It is difficult to imagine what prompted Sabatier
in the description of this method, and why he directs the removal of the
flap rather than its preservation. * By dissecting it up, as M. Gouraud did, in
1801, and as it has recently been done by Dr. Smith, in America, the operator
can easily extract and. excise the bone.
5. Bent^s Method. — After in vain trying White's method. Bent, who was
one of the first to remove the humerus, thought it was necessary to detach it
outwardly from the acromion, inwardly from the clavicle, and then to divide
the deltoid muscles transversely, so as to form a T incision, which would per-
mit him to dissect the two triangular flaps, one external and the other internal,
and afterwards act freely upon the joint.
6. M. MorePs Method. — M. Morel was dissatisfied with all these methods,
and made a semilunar flap, with the convexity downwards, upon the anterior
face of the shoulder. The operation was long, but the patient was cured.
7. Mr. Lyme^ who has twice removed the head of this bone with success,
makes a flap upon the external half of the deltoid, giving it a triangular form,
the anterior leg of which is represented by White's incision, whilst the other,
much shorter, is carried obliquely upward and backward towards the poste-
rior edge of the arm-pit. The flap being raised, the surgeon carries the elbow
in front of the thorax; divides the capsule, luxates the head of the hu-
merus ; excises it ; brings down the flap, and proceeds to the dressing.
Remarks, — The diseases which call for excision of the humerus, are t|id
35 "
j^4 NEW ELEMENTS OF
same as those which otherwise would require disarticulation of the arm ; con-
sequently the various methods of operating proposed for the latter will also
apply to the former. Thus instead of making a flap by means of three inci-
sions, as La Faye did, it would be much more simple to imitate M. Morel, or
to make a single cut as MM. Dupuytren and Lisfranc do, or even to follow
the method of Mr. Cline or Onsenort. It is also evident that excision differs
from amputation at the joint, only in the latter steps of the operation.
We may therefore adopt any method that may appear most easily to isolate
the head of the bone, either by penetrating from above downwards, from
without inwards, or in any other manner, and just as teguments and
muscles may be more or less altered in this or that direction. Whatever
method we select, Mr. Guthrie recommends us to remove as much of the
articular capsule as possible ; because, says he, the more there is left of this
fibrous purse, the less will be the chances of an immediate reunion. This
practice, although good in amputations, is not to be followed in excision ;
because, in proportion to the preservation of the fibrous tissues will be the
future strength and stability of the limb. When the extremity of the hu-
meus is removed, the operator can assure himself of the state of the acromion,
of the corocoid apophysis, and the glenoid extremity of the scapula. If
these parts be not altered, he then proceeds to the dressing ; otherwise, he
must remove them with the cutting Ibrceps, the gouge or chisel, or even with
the sawj proceeding as we have described in the removal of the shoulder ;
that is to say, if the alteration of the bone extends beyond a certain distance, it
will be necessary to extend the ineisions which circumscribe the base of the
flap, under the spine of the scapula, and above the internal edge of the cora-
coid process, in order to expose the whole extent of the diseased parts. It is
well known that M. Larrey does not hesitate to remove these three apophyses,
aftd even the acromial extremity of the clavicle. Mr. H. Hunt proceeded in
the same manner in a case in which Mr. Brown, in 1818, had removed the head
of the humerus. This daring effort was crowned with complete success.
Moreau had this excision in view when he recommended turning the del-
toid downwards. Then, in fact, nothino; prevents us from forming another flap
in the opposite direction, which would render the removal of the scapular
apophyses quite easy. But as it is always possible to retain sufficient sub-
stance at the root of the flaps of La Faye, Dupuytren, or Lisfranc, to prevent
mortification, the motive that influenced Moreau will not sufiice to make us
pursue his method, after seeing that of the other operators. The operation
being finished, the extremity of the body of the humerus is returned to its
natural place by giving the arm its natural direction. Whatever may be the
fonn of the flap, its lips must be exactly brought together, at least towards
the lower angles of the solution of continuity. To retain the bleeding
surfaces in contact, the origin of the limb should be covered with plates of
agaric, pledgets of charpie, or graduated compresses. A many-tailed band-
age, cushions and splints, should fix the whole in such a manner as to per-
mit the dressing of the disease as often as it may be judged advisable.
Some have thought that the portion of the bone removed would be repro-
duced. This is an error. From the case given by Chaussier, it is seen
that a conical osseus mass fills up the glenoid cavity, ending, it is true, by com-
ing in contact with the superior extremity of the body of the humerus^^and
OPERATIVE SURGERY. 275^
being slightly excavated, really produces a new articulation that allows the
arm almost all its original movements. In one of tlie cases reported by Mo-
reau, the superior part of the bone of the arm was drawn and fixed upon the
breast, when a sort of artificial articulation was ultimately formed. But
nothing in these cases indicated a reproduction of the bone, and most fre-
quently the superior extremity of the humerus remains movable in the midst of
the soft parts. Nevertheless, the patient preserved the motion of the fingers,
the hand, and the fore-arm, and even most frequently could move the mem-
ber to a certain distance in every direction ; only he is unable to raise it at a'
right angle with the trunk, or to hold it far from the breast. After such
an operation, it is infirm; but it is better to have a limb deformed, and some-
what reduced in its functions, than none at all, and the last cases reported by
Mr. Lyme demonstrate that the use of the arm may be almost entirely re-
stored.
Art. 6.— The Clavicle,
The clavicle is situated very superficially, it is true ; but as it covers some
organs, the wounding of which would be very dangerous, surgeons have not'
dared to attempt its excision, except in cases which have just been stated.
Yet there are circumstances sufficiently numerous, which require this opera-
tion, if we wish not to abandon the sufferers to certain death. Sometimes
necrosis or caries may affect its scapula, sometimes its sternal extremity ;
sometimes its middle, or even throughout its whole extent. The mode of
making the excision or extirpation, is difficult to lay down, because the disease
that requires it may produce. numerous changes in the anatomical disposition
of the neighboring parts.
1st. Acromial Extremity. — In a woman affected for a long time with necrosis
of the external third of the clavicle, I first made a crucial incision, the
branches of which were each about four inches long. After dissecting and
separating the two flaps, and dividing the acromio-clavicular ligaments,
together with some fasiculae, from the origin of the deltoid and trapezius
muscles, I was able, with the assistance of a plate of wood sunk into tlie arti-
culation as a lever, to raise up the diseased bone, an<i thus detach it from thie
healthy parts. If it had offered too much resistance, a common saw, or,
better still, a cock's-comb saw would have enabled me to make the section
downwards or backwards. Supposing it had been too much buried, I would
have carefully isolated it from the soft parts before and behind, passed one of
Jeffrey's chain-saws under its inferior face, and cut it from behind forward,
and then disarticulated and removed it. If the skin be not ulcerated, nor
positively diseased, we would succeed as well, and, I think, even better, by
making a triangular flap, by means of a transverse incision parallel to the
internal edge and some lines below the clavicle, to be prolonged to the summit
of the acromion ; then another, much shorter, meeting the internal extremity
of the first at a right angle. This flap, turned back, completely exposes the
diseased bone, and will permit the application of the saw upon the sternal side
of the diseased part, which, after the division, may with a bistoury and forceps,
or an elevator, be removed as far as the acromion. This method would
be more easily applicable to the sternal moiety of the clavicle ; but in
either case, on account of the axillary vessels, the operation becomes the more
276 NEW ELEMENTS OP
delicate and dangerous, in proportion as the saw is applied nearer the middle
of the bone.
B. Extirpation. — From the dead subject the clavicle is not difficult to
remove. An incision, parallel to its cutaneous edge, reaching a little beyond
its extremities, is commonly sufficient. Or two vertical incisions, about one or
two inches long, may be added one to each extremity of the first, and then by
dissecting up the flap, the bone may be completely uncovered. Then the
operator may disarticulate it at either extremity, and seizing it M'ith his left
hand, detach it from its internal adhesions by the right, armed with a bistoury.
The bone may also be sawed near its centre, and the two moieties separately
removed. In a diseased state of the parts, this operation must be one of the
most difficult in surgery. It was, however, once performed with complete
success, by Dr. Mott, on the 17th of June, 1827, in New York, on a young
man aged nineteen years, affected with osteo-sarcoma.
The tumor was as large as two fists, extending from near the angle of the
jaw and the os hyoides in one direction to the point of the shoulder, and the
sterno-clavicular articulation in the other. The operation was very laborious.
It was necessary to apply more than forty ligatures before it was completed.
Dr. Mott commenced by making a semilunar incision with its convexity
downwards, and reaching from one extremity of the clavicle to the other, as if
to detach the tumor from below upwards ; he then made a second, extending
from the acromion to the outer edge of tlie external jugular vein ; divided the
platysma myoides, and a portion of the trapezius ; passed first a grooved
director, and then, by means of an eyed probe, a small chain-saw under the
clavicle, which he divided a little nearer the acromion than the coracoid
apophysis. Being yet unable to turn out the morbid mass, the operator con-
nected the two other incisions by a third, at their sternal extremities ; tied the
external jugular at two points, dividing it in the interval ; divided the ex-
ternal portion of the sterno -mastoid muscle two inches above its origin, and
turned it down upon the sternum; separated and pushed the omo-hyoideus
muscle, upwards and backwards; was also obliged to tie and divide the
internal jugular, and to separate with some difficulty, by means of the bistoury
or the handle of a scalpel^ the subclavian vein, and even the thoracic duct from
the degenerated tissues ; numerous branches, coming, no doubt, from the
inferior thyroid, transverse, cervical, subscapular, &c., arteries, were tied as
soon as divided A last incision, the utility of which I cannot comprehend,
was made over the line of the fourth rib, beginning at the first, and dividing
the fibres of the great pectoral muscle. After dividing the costo-clavicular
ligament and subclavian muscle. Dr. Mott was at last enabled to raise the
tumor, and concluded by disarticulating the bone at its sternal extremity.
The wound was filled with charpie, and long adhesive strips used to
hold its lips as near together as possible. No serious accident followed. The
cure was nearly completed by the last of July, and by means of an appropri-
ate machine, wliich to a certain extent supplied the place of the clavicle, the
patient retained almost the entire use of the arm.
As such an operation should not be attempted but by the most skillful sur-
geon, it is useless, I think, to enter into any details, to show in what manner
Dr. Mott's method could be advantageously modified. All such persons will
easily conceive them, by recollecting the anatomy pf the aifected region, and
<M»ERA^TIYE SURGERY. 273^
of course will have to conduct themselves according to trie peculiar characters
of the disease. Thus it was with M.Beauchene,who, being obliged more than
ten years ago to remove a great part of this bone, and the rest of the shoulder,
at Saint Antoine, made use of diiferent incisions from those of Dr. Mott.
M. Lucke found himself in the same situation in the excision of the shoulder,
of which I have just spoken. Kulm, who extracted the clavicle in the early
part of last century for a sarcoma of five pounds' weight, had also to invent
his own method. Nor do I see why the ligature of the mass, so much
extolled by M. Mayor, might not be practised, since the hemorrhage seems
so difficult to arrest. The excision of the body of the scapula would be
even more variable than that of the clavicle.
M. Jansan, who has performed it, began by circumscribing the tumor by
two semi-elliptical incisions, taking care to preserve as much of the skin as
possible; dissected up and turned back the two lips of the wound ; detached
the diseased mass in every direction as far as the subscapular fossa ; but whilst
he was raising it up it broke in the middle, and he was forced to separate the
external half first. After dividing the attachments of the trapezius, the
supra and infra spinatus muscles, the operator having discovered that the por-
tion of the bone above the spine was healthy, separated from it all the diseased
portion with a saw, and thus preserved the articulation of the arm. By
another and the lastincision, made obliquely upwards, forwards, and inwards,
he exposed the whole tumor, dissected it carefully, lifted it up gently, felt
the cellular tissue that fixed it to the arm, wliich he tore, and at last succeeded
in detaching it entirely.
All the vessels were tied. The hollow of the arm-pit was filled with lint,
and by the assistance of adhesive strips the lips of the wound were brought
together, although the incision measured six inches in its transverse, and
nine inches in its longitudinal diameter. The movements of the arm upon
the glenoid cavity were preserved. The tumor weighed eight pounds and a
half, was easily torn, and presented the aspect of the interior of a pomegranate.
SECTION II.
Abdominal Members,
If it be difficult to disprove at the present day the advantages of incision
when applied to the thoracic, the same cannot be said as to the pelvic mem-
bers. Here, an artificial member may supply almost all the functions of
the natural one. There, on the contrary no machine can be so adapted as to
render the same services to the patient. Whatever may be the deformity left
in the arm, or in whatever state the hand may be, if they be preserved, they
may always answer some useful purpose. Notwithstanding this, excision has
been recommended for all the articulations of the inferior members, and even
performed a certain number of times. Having treated of excision and ex-
traction of the bones of the feet, in the article Jlmputation, I shall not recur
to it, especially as they are governed by the same rules as those of the bones
of the hand.
278 . . HEW ELEMENTS -OF
*^rt.\. — Tibio-tarsal Articulation, pH?^
Gooch long since excised the inferior extremity of the tibia with success.
This operation has been repeated by Cooper, De Bungay, Hey, Deschamps,
White, and Taylor; and more recently by M. Delpech, and the Moreaux,
father and son. MM. Jesse and Ladent, have been equally successful in
excising the tarsal extremity of both tlie bones of the leg, although they had to
remove two inches of the tibia on the right, and an inch and a half of both
tibia and fibula on the left, in the case of a young girl. At the end of three
months the patient could walk with a stick, which she has since laid aside.
In almost all of these cases, excision was decided upon, it is true, but in con-
sequence of complicated luxations or comminuted fractures. But many
have also performed it for organic lesions, i. e., while the parts retained
their natural positions.
Operation. — 1st. Moreau's Metliod.- — M. Moreau recommends two inci-
sions to be made on each side of the leg, one extending from the summit of
the malleolus, three or four inches above, the other commencing at the same
point, and carried forwards transversely to the insertion of the peroneusbrevis
on the external, or to the corresponding tibialis for the inner side. The
longitudinal incisions should go to the bone, but the others only through the
skin. He commences, by dissecting the external flap, to disengage the fibula
from the tendons that surround it, and then divides it with a chisel or cock's-
comb saw above the disease, and disarticulates it from above downwards, by
dividing the fibrous fascia that connects it to the tibia, astragalus, and os
calcis. The same course is pursued in isolating the tibia from the soft parts,
and in dividing and disarticulating it. If the astragalus be diseased, it also
must be removed totally or in part, as has been done by M. Moreau, the younger,'
After the operation the foot must be brought to the inferior extremity of the
leg, and kept there by adhesive plasters and a suitable bandage.
2d. M. Roux^s Method. — This is exactly the same operation as for the carpal
extremity of the fore-arm. Instead of the chisel and mallet, the chain-saw
of Dr. Jeffrey is better adapted to the tibio-tarsal articulation than anywhere
else. Notwithstanding the narrowness of the interosseous space, M. Roux
once succeeded in passing a compress through it, which enabled him to saw-
first the fibula and then the tibia without fear, having first brought it between
the bone and the soft parts.
Fa/wc.'^This excision, always difficult, may be sometimes followed by the
most serious consequences. M. Roux's patient ultimately succumbed. After
the most complete cure the member must necessarily lose some of its length,
and the patient can walk only with the assistance of a more or less elevated
shoe. It has no advantage over amputation. It seems to me that the exci-'
sion of the tibia only can never accomplish the object the surgeon proposes.'^
The foot, losing its principal support, will be in fact incapable of sustaining
the weight of the body, and will be turned inwards, as M. Moreau, the younger,
has observed in one of his patients. It would seem then, that the fibula, even
when sound, must be excised whenever the tibia is to be removed. The parts
to be preserved are, first, anteriorly, the tendons of the anterior tibial, some
of the extensors, and the peroneus brevis ; second, on the outside, the peroneus
longus; third, on the inside, the tibialis posticus and the flexors; fourth.
vi#PERATlVE SURGERY. 27*9
behind, the semi -tendinous portion of these muscles ; fifth, and lastly, the an-
terior tibial artery in front, and then the posterior tibial behind the internal
malleolus.
^rt. 2.— The Knee,
History. — The excision of the bones forming the femuro-tibial articulation,
first recommended by White, has been put in practice twelve times ; once
by Park, with sufficient success to enable the patient to walk without the
assistance of a stick; a second time, without success, the patient dying
after some months from exhaustion; a third time, by Moreau, senior; twice
by Moreau, jun., one of whose cases died three months after the operation,
the other was for a long time obliged to use crutches. A case was pre-
sented by Mulder, in 1809. M. Roux has published a seventh. His pa-
tient died on the nineteenth day; the case was reported in 1815, to M.
Gourard, by M. Haime, of Tours. Mr. Crampton performed it twice,
first, on a young woman aged twenty -three, on the 7th of May, 1823, and the
second, in 1824. The first recovered, and actually walked without crutches,
notwithstanding the deformity of the member. The other died from the
effects of the operation. Mr. Lyme has also had recourse to it twice ; one of
his patients died ; the other, a child nine years old, recovered, and walks very
well. According to this author, it has also been once attempted in Germany.
It certainly is not because of its difficulties that excision of the knee should
be proscribed, but because it is infinitely more painful, tedious, and dan-
gerous, either immediately or secondarily, than amputation in the continuity
of the thigh, and especially because, in the most fortunate cases, the preserved
member is really less useful to the patient than an artificial leg. A shortening
of from four to eight inches is necessarily produced. The articulation cannot
be re-established. If the limb retains its faculty of moving, it is very irregu-
larly, and is almost always very much bent outwards. Experience has con-
firmed all this. Of the eleven patients, the history of whose cases is known ,
five at least have succumbed. Some, like the patients of M. Roux, very sud-
denly; others, after long continued suffering. Almost all who have been
cured, owe their recovery to the most extraordinary care, whilst they have
run the greatest risk of losing their lives. Yet it is certain, whatever Mr.
Lyme may say, that none can use the preserved, with the same advantage
that they could use an artificial limb. The following methods should be
adopted, when the operation is undertaken.
Operation. — 1st. Mr. Parle's Method. — A crucial incision, the transverse
branch of which placed above the patella should comprehend one half of the cir-
cumference of the member, is the characteristic feature of Mr. Park's method.
After having divided* the tendon of the extensor muscles, everted the four
flaps, raised, up the patella, divided the lateral ligaments, pierced the
articulation from before backwards, he pushed a large knife under the pos-
terior face of the femur, to separate it from the soft parts, taking care of the
popliteal vessels, and sawed the bone above the condyles.
2d. M. Moreau^ s Method. — The articulation of the knee being very simir
lar to that of the elbow, M. Moreau thought that the excision of one should be
280 \EW ELEMENTS O/** "
performed like that of the other. Accordingly he commenced by making two
lateral incisions a little behind tlie borders of the ham; which were terminated
at the bottom by a transverse incision, uniting them ; and divided the skin and
the end of the triceps femoris below the patella, so as to reach the articulation ;
then denuded the posterior face of the bone from the surrounding flesh; the
quadrilateral flap, made by the three incisions, was then dissected and raised
up ; and the section of the femur made with the same caution, as by Park. If
the bone of the leg be at the same time affected, the external incision should be
prolonged to the head of the fibula. Another should be made over the crest of the
tibia, thereby forming two lower flaps, one internal the other external, which
are to be dissected and depressed. The posterior face of the tibia is^ to be
isolated from the vessels and nerves, as well as the head of the gastrocnemii
muscles, so as to be able to remove the whole of the diseased bone with the
saw.
3. MM. Sanson and Begin'^s Method. — Instead of making first a large
quadrilateral flap, the new editors of Sabatier commence by a transverse in-
cision below the patella, extending from one lateral ligament to the other, and
penetrating at the first cut into the articulation. This done, they disarticulate
the femur or tibia only, if there be but one of them diseased, by making two
lateral incisions from the extremities of the first, upwards or downwards, and
shorter or longer, according to the length and situation of the aftected portion
of the bone.
4. Mr. Lyme's Method differs from all the preceding in more than one
respect. This operator makes two semilunar incisions in front of the joint,
one above and the other below, which are united on a line with the lateral liga-
ments, and form a transverse ellipsis enclosing the patella. He excises this
ellipsis and the bone contained in it ; divides the ligaments, opens the arti-
culation, and removes, one after the other, the extremities of the femur and
tibia.
Remarks. — Whatever method may be followed, the bleeding surfaces
must be brought together, and occupy the place of the removed bone; a few
stitches or adhesive strips, some charpie, compresses, cushions, splints, and,
in fine, all the apparatus for a complicated fracture of the leg, are necessary
to complete the dressing, and hold the limb in the most perfect state of rest.
These various methods all permit the accomplishment of the.object in view.
The operation is alike possible, whether we make a crucial incision, like Park,
or a quadrilateral flap, like Moreau, or penetrate the joint at the first stroke
like Sanson and Begin, or remove or not the patella, like Mr. Lyme. It
is the consequences, and not the operation that are so dangerous, and which
should, in my opinion, cause it to be generally proscribed. I would admit
no exception, but where the articulating surfaces alone are diseased, so as
to permit the removal of the whole disease without excising more than one or
two inches of each bone. i*
If the rotula be carious, or affected with necrosis, it should be removed
without hesitation, even if the joint should be opened. One such case
only is known in medicine, and in that the disease was cured. I have seen
two persons in whom it was fractured, and although the fragments were sepa-
rated more than six inches, they preserved the use of the leg.
OPERATIVE SURGEHY. £81
JlrU 3. — Head of the Femur »
Toward the middle of last century, White ventured to propose the disar-
ticulation of the femur, and the excision of its superior extremity. A simple
incision was to enable him to expose the articulation, open the capsule, luxate
the bone, and turn it out for excision. Vermandois and Petit-Radel revived
tliis idea without any modification. But Rossi soon saw that the incision
proposed by White was insufficient, and that it would be more easy to reach
the joint by making externally a triangular flap. Chaussier, nearly thirty years
ago, made a number. of experiments upon this subject, and excisions in
general. According to him, excision of the head of the femur in dogs is not much
more dangerous than that of the humerus. There forms in place of the ex-
cised bone, a matter first fibro-cellular, then cartilaginous, and finally, so
solid as almost to equal the hardness of the bone itself. Wachter expresses
himself nearly in the same terms in his dissertation. Still there is at present
but one case given of the e^^cision of the head of the femur, and the results
attending it, as given in the American journals, are so strange, that it is diffi-
cult to give tliem entire credence.
If the head of the femur should escape through the torn soft parts and
could not be reduced, it might, without doubt, indeed it should be removed
with the saw, and especially if it be fractured ; but what is the disease so
serious as to require removal of the head of the femur, that would attack
it without also implicating the cotyloid cavity ? and when the bones of the
pelvis are diseased, of what use would it be to excise the femur ? However,
if some one should desire to attempt it, the most simple method would be,
provided there already existed no external wound, to make a simple semilunar
incision, extending from the antero- superior spinous process of the ileum to the
tuberosity of the ischium, forming thereby a large flap with its convexity
below, behind the articulation, and at the expense of the soft parts at the
origin of the limb. After having raised this flap up and divided the posterior
half of the capsule, abduct and flex the thigh at the same moment to divide
the inter-articular ligament; pass the knife between the head of the bone and
the cotyloid cavity, inward and forward to the groove at the neck of the femur
to detach the rest of the capsular ligament, and turn out the portion of the
bone to be removed. After its removal, there will be little else to do than
return the thigh to its natural position, bring down the flap, and secure it with
stitches or adhesive strips, and for the rest pursue the course usual in com-,
plicated fractures of the superior part of the bone.
Artificial Articulation. — Some operators have made use of another kind of
operation on the femur. When the hip is anchylosed, they have proposed a
kind of new joint by sawing the bone near the body or at the neck, and
even by excising a portion if judged prudent. Twice already has this
daring operation been attempted in America. The first time, in Novem-
ber, 1826, with entire success, by Dr. J. R. Barton; and the second, by
Dr. Rogers, at tlie hospi^l of Philadelphia. I understand from Dr. Buck,
that in the last case, the patient, who for some time gave strong hopes of a
second instance of success, ultimately died. Without wishing to become its
36 ,
€Sf NEW ELEMENTS OF^
defender, I would however remark, that with the aid of an incision over the
external and superior part of the member, or of a crucial incision, and one of
Jeffrey's chain-saws, or an elastic, or even a small hand saw. Barton's ope-
ration is much less difficult than one would at first imagine. And I would
add, as to the probability of its effects, that in a case, published by M. Pailloux,
of false articulation of this joint following the fracture of the neck of the
femur, the patient walked very well before his death ; and that M. Martin
has found another case of false articulation of the same species, between the
great trochanter and body of the bone, the head of it being destroyed; and,
in fine, that the number of non-consolidated fractures of the part, justify to a
certain extent, this apparently dangerous operation.
'tm
TITLE IV.— TREPANNING.
Trepanning appears to have been practised from the highest antiquity.
Its origin is lost in the obscurity of time. It is used on almost all the bones
«f the body, but especially on those of the head.
CHAPTER I.
THE CRANIUM.
Notwithstanding the improvements it received from the physicians of an-
cient Greece, and the abuse it suffered in the middle ages from those
charlatans that Sylvaticus called circulatores, trepanning is one of the opera-
tions that has most strongly attracted the attention of surgeons, since the
time of G. de Chauliac. For a long time it was thought the principle and
almost only remedy for the traumatic lesions of the head, produced by blows,
falls, &c. At the present it is but rarely resorted to. No person would
think now of imitating Panaroli, in trepanning for a simple chronic cephalalgia,
even if it were most violent, or of venereal origin ; nor for epilepsy, although
Marchetti lias used it once successfully, and M. A. Severin has formally
recommended it for that disease ; nor for fractures of the inner table of the
bone, for which Garengeot speaks of using it ; nor for remedying an attrition
or simple contusion of the diploe, as Acrel, Richter, and Fritz recommend.
Mr. Ramsden, as stated by "Mr. S. Cooper, has seen a patient, on whom the os
frontis had been perforated for a simple sub-orbitary pain, die of meningitis
the fourth day after the operation.
OnSRATIVE SURGERY. 28$
Indications. — Its object being to give exit to foreign fluids extravasated in
the cranial cavitj, to permit the elevation or removal of any fragments of
bone or other bodies that may have been forced in upon the brain, and whose
presence may impede the functions of that organ, there arise indications very
difficult to appreciate. Nothing is more vague, than tlie signs by the aid
of which authors pretend to recognize the various lesions for which they
use it. The sound of a broken kettle, perceived at the moment of the acci-
dent, and the sound given by percussion on the bone with a small stick, recom-^
mended by Lanfranc, are altogether insignificant. The same may be said of
the tendency of some patients to carry their hands mechanically to some cer-
tain point of the head ; of a shock felt by others the moment that a piece of
thread or string, held between the teeth, is snatched from the mouth ; of the
painful sensation produced by a deep inspiration, and upon which Roger, of
Parma, so much insisted. All these signs may be wanting although there is a
fracture, or on the contrary exist as accompaniments of much less important
lesions. Besides it is not the fraction, properly speaking, but the compression
produced by it, that justifies the use of the trepan. Whether the effusion be
sanguineous or purulent is also as difficult to determine, whilst it is extremely
difficult frequently to designate its exact seat. Sometimes, in fact, it is
immediately under the point struck that this extravasation is found, some-
times at a point directly opposite, and frequently at some point less distant.
The paralysis, which indicates the seat of the affection to be on the opposite
side of the head, may be met with on the corresponding side. If the integu-
ments of the head be in nowise diseased, if there be no contusion nor solu-
tion of continuity to be observed, it is almost impossible to guess within half
an inch, often indeed within several inches, of the exact seat of the collection.
The application of a cataplasm over all the head, recommended by some of
the ancients, in order to discover the spot where the application is most rapidly
dried — a spot corresponding to the disease — is a puerile resource long since
appreciated at its just value.
On the other hand, as these aflTections, even when considerable, have been
seen to disappear without trepanning, and as even fractures with depressions
of near an inch, of which Physick, Horner, Paillard, Gragfe, &c. each report
a case, have also alloNved of the recovery of the sufferers, without an opera-
tion, Desault and his followers, combating the doctrine of the ancients, of
Garengeot, J. L. Petit, de Quesnay, Pott, and all the academy of surgery,
and returning to the ideas of Van Wyck, Aitkin, and Metzger, have esta-
blished as a general position that the operation of trepanning is most frequently
injurious, and tliat it should consequently be dispensed with in almost all
the cases in which the surgeons of the last century recommended it. This
doctrine, supported by the researches of M. Jftriot, sustained by Professor
Graefe, at Berlin, and which the English surgeons have adopted, prevails very
generally in France, and has just found an ardent defender in M. Gama. Still
some able surgeons, such as M. Larrey, M. Roux, M. Dupuytren, and M.
Delpech, among others, have used the trepan successfully at the hospitals
of the Garde JRoyale, La Charitie, and Hotel-Dieu, I know also of a
surgeon of Chauteau-du-Loir, who performed it some years ago with entire
success for a purulent collection, the existence of which was only known by
pains and symptoms of paralysis. In 1823, Beclard and M. P. Dubois were
^d4 NEW ELEMENTS OF
not less4iappy Avith a subject affected with fracture without displacement, al-
though they were obliged to take out three circles of bone in the temporal
fossa, and to extract nearly eight ounces of blood furnished by the arteria me-
ningea. And in 1825, M. Touissaint reported an instance of success of
the same kind, which he obtained by the application of the crown of the trepan
six times.
Thus then, without being as prodigal of trepanningas surgeons were before
the time of Desault, or without admitting, with MM. Foville and Florens, that
it may be useful in relieving the organ from compression in inflammatory or
other defluxions of the brain, it would seem that it should be at least more
frequently used than is now customary. If it be true that we are often em-
barrassed in ascertaining the seat and nature of the disease that indicates its
use, it is equally true that in some cases the thing is not beyond the reach of
an intelligent surgeon. Besides, when it is decided to attempt it, the patients
are in such an alarming state, that a simple perforation of the cranium cannot
add much to the dangers that menace them. If then we learn in any manner
to a certainty, that a foreign body, such as a splinter or angle of bone be the
cause of the alarming symptoms, we should trepan ; it is even necessary for
long standing or consecutive effusions, indicated by necrosis of the bone
separation of the pericranium, black color of the neighboring tissues, pale
aspect of the lips of the wound, crepitation of the cranial integuments, &c.
Parts of the Cranium that admit of its Application. — The operation having
been determined upon, another question presents itself — upon what point
shall it be made ? It was formerly a rule that the trepan should not be applied
above a horizontal line, which would separate the base from the arch of the
cranium, passing through the nasal projection, and over the external occipital
protuberance ; nor over the sutures; nor over the course of sinuses of the dura-
mater, the frontal sinuses, the temporal fossa, the anteror-inferior angle of
the parietal bones, &c. But Beranger de Carpj, Cortesius, Hoffman,
Bromfield, and Pallas, trepanned over the sutures with complete success.
Acrel, Wurm, and many others, have perforated the frontal sinuses with
advantage. Warner, Marchetti, Garengeot, Sharp, Potts, Callisen, Mosque,
and Lassus, have opened various sinuses of the dura-mater, without any
unhappy result ; and the new experiments of M. Flourens upon animals, tend
to prove that this may be done almost without any inconveniences resulting.
Carcano and Job a Meckren, had the boldness to trepan over the temporal
fossa, without meeting with any impediments from the fibres of the temporal
muscle ; and Bilguer, Copland, Gooch, Abernethy, and Hutchison have ex-
posed the brain in perforating through the occipital bone. When the trepan
is applied over the sutures, and the body to be extracted is found immediately
below, then the adhesions must necessarily have been destroyed ; but if that
be not the seat of the disease, the operation must be performed upon another
point. Over the frontal sinus, MM. Larrey, Boyer, S. Cooper, and C. Bell,
remark, that to avoid a lesion of the membranes it is sufficient to commence
the operation with a crown larger than the one with which you terminate.
Besides, what danger is there here of wounding the dura-mater ? When the
venous sinuses are opened, the hemorrhage, so much dreaded by the ancients,
.^tops of itself, or is easily stopped with'simple dressing. Over the protube-
riisces of the cerebellum there are no arterial branches of importance, except
OPERATIVE SURGERY. 285
the occipital, and the lesion of the trapezius or complexus muscles is not of
much consequence. In the temporal fossa, the division of the muscle, in
whatever manner the operation may be performed, will not prevent the re-
establishment of its functions.. As to the opening of the arteria meningea, it
will be easy to remedy, either by means of some lint fastened by a thread to
the interior of the cranium, as Dr. Physick has done,; or by cauterization with
a stylet heated white, like M. Larrey ; with a piece of cork, a morsel of wax,
or a strip of lead, curved in such a manner as to compress both faces of the
bone and the groove that encloses the artery, as successfully performed by
Dr. Dorsey, of Maryland. Sabatier, renewing the precept of Lan franc, advises
the crowns of the trepan to be placed at the lowest point of the effusion. Aa
it is almost always possible, by varying the position of the patient, to turn the
opening of the cranium below ; as it is more frequently for the extraction of
a solid foreign body than to give vent to liquid matters ; and as it is rare that
the extent of the seat of the injuring cause is considerable, this precept is less
important in practice than it would at first appear to be.
Apparatus. — Hippocrates mentions a scraper, known by the name of xistre,
with which he scraped the bones to thin them, or to discover the sutures.
His trepan was a sort of drill, operating like a gimlet. He speaks, however,
of another, which must have had some analogy to the crown more recently
described. Cetsus gives this crown the name of modiolus ; without doubt,
says Guy de Chauliac, because it resembles a small hogshead {muid). He
compares the trepan, properly so called, to a carpenter's auger. Galen is the
first who speaks of ahaptist trepans, that is, with crowns or perforators,
surrounded by a collar or sheath, which prevented it from penetrating too
deep. These abaptistes, which are also spoken of in the works of Lanfranc,
and a great many other surgeons, have been for a long time rejected from
practice. A double convex knife, the gouge and chisel, as well as the meningo-
phylax, a sort of blade terminated by a flat knob or button, intended to push
the compress between the dura-mater and the bone during the dressing, was
employed from the time of Heliodorus and Galen. We find still further, in
the work of Andre de Lacroix, the cutting forceps, the punch, and the elevator,
as well as the idea of the famous triploide, recommended by Scultetus, and of
which J. L. Petit has taken pains to show the inconveniences. The agents
at present used, and which are commonly placed together in a box, are a
trepan, properly so called, with its shaft and its crowns, a punch, a pyramid
and its key, elevators, a lenticular knife, a chisel, a cutting forceps, a cock's-
comb saw, a small brush, and a leaden mallet.
Operation. — The patient, lying on a bed, having his head supported upon a
pillow, below which a plank or metallic plate should be placed, is held in this
position by the assistants.
First Step. — The operator, armed with a straight, thick, and sharp bistoury,
enlarges more or less in various directions the solutions of continuity, if there
be any. If none'' exist, the operator makes on the integuments previously
shaven an incision, the form of which varies with different surgeons.
Lanfranc, G. de Chauliac, and Lassus recommend that it should resemble a
7 inverted. Van Swieten, an X ; and that the flaps should be excised. At
present it has generally the form of a T, or a cross. When operating over
the temporal region, cotemporary authors, as Sabatier and Richerand, recom-
286 NEW ELEMENTS oF
mend that it Imve the form of a V, with the base above, which, according to
them, will divide but few of the fleshy fibres. If the summit of the V com-
prehends a transverse extent of the temporal muscle less than that of the base,
the operator must still divide all the fibres ccmprehended between the two
extremities of the latter. It is a long time since circular and triangular incisions,
and all those by which the flaps were removed, have ceased to be recommended
by any surgeon. Whatever Pott may have said of it, the crucial incision is
the one that merits the preference. When there is no fear of sinking into
fissures, the bistoury may be carried to the bone at the first cut. TItc flaps
being turned up, covered with fine linen, and held back by the assistant's
fingers, the operator has been directed to destroy the pericranium with the
scraper. This is a useless and even injurious precaution. The pericranium
does not oppose the action of the trepan. The wounding of it with the saw is
riot more dangerous than that produced by tearing it with the scraper. By
making immediate use of the trepan, no more than the necessary circle is torn ;
whilst with a scraper, it is disruptured always to a certain distance beyond,
which necessarily becomes exposed to necrosis. The vascular lines, which
even Hippocrates notices as being liable to be mistaken for fissures, will not
he effaced by the scraper, especially if they coincide with an abnormal depres-
sion of one of the frontal protuberances, and are somewhat deep, as I have
recently seen them at La Fitie. It will evidently be of no assistance in
distinguishing a true fissure from the lateral suture, sometimes observed on the
parietal ; from the deviations of the sagittal suture, mentioned by Van Swieten
and Quaisnay ; or the accidental disposition of the wormian bones, which
failed to deceive Saucerotte. Still, if the operator desire to use this instru-
ment, he takes it in the right hand by the handle, with the plate between the
tliumb and index finger, handling it in such a manner that it shall neither
leave any part untouched, nor denude more than is desired.
Second Step. — When the trephine, which the English almost exclusively
adopt, is used, and of which M. Withusen has recently become the advo-
cate in Germany, the surgeon, holding it in his hand by the handle, makes it
act like a gimlet or cork-screw. If, on the contrary, the trepan be preferred,
the crown is placed on it, and then, taking hold of the stock with the right
hand as if holding a pen, the operator places the point of the pyramid upon
the centre of the piece of bone to be removed ; presses upon the crown to
mark this point, whilst the other hand supports the rest of the instrument;
then removes the crown, and puts in its place the perforator, the summit of
•which he puts in the point marked by the pyramid ; embraces the ebony
plate that terminates the handle of the trepan circularly between the thumb
and index-finger of the left hand ; presses upon this plate with the chin or
forehead ; takes hold of the shaft of the trepan with the right hand ; gives it
two or three turns from right to left ; puts the crown in place of the perforator;
takes hold of the instrument as when first using it ; fixes the pyramid in the
hole just made, and turns it again as just stated, taking care to press equally
on all the teeth of the saw, in order to form the circular groove as regular as
possible. When this groove has been made deep enough to prevent the crown
from escaping from it, the pyramid should be removed. Otherwise it would
render the operation longer and more ^ngerous; reaching below the level
of the crown, it would necessarily reach the membranes before the completion
OPERATIVE SURGERY. 2^7
of the section of the bone. The trepan having been again placed in its groove,
the surgeon should use it rapidly, inasmuch as it is still at some distance from
the dura-mater, withdrawing it from time to time to see if the section be
regular, to clear the teeth with the brush, and also, as Hippocrates remarked,,
to prevent its becoming too much heated ; when it has passed the diploe^ use
it gradually more slowly ; from time to time attempt with the elevator or
other suitable piece of metal to move the osseous disk formed by the crown,
and cease entirely from using the trepan as Soon as a certain cracking noise
is heard, which it will be impossible to confound with any other sound when
once heard, and which indicates that the operator has reached the membranes.
When the osseous plate is completely divided, it sometimes comes away with
the- crown of the instrument. In other cases it is removed by an elevator of
any kind, used as a lever of the first class.
Third Step.^—li the section be regular, it is useless to apply any other in-
strument ; but if there be left in its deeper parts any points or sharp scales,
it will be proper to apply the lenticular knife, placing the button between the
dura-mater and the bone, passing it, edge foremost, entirely around the cir-
cumference of the orifice in the bone. If it be the seat of the disease, the
matter begins immediately to be discharged. If there be a foreign solid body,
it is to be seized and removed with the forceps, or any other appropriate in-
strument. Sometimes we meet w^itli an effusion extending some distance
from the point on which we have operated, and if it consist of coagulated blood,
or other plasiic matter, a single perforation is insufficient for its escape. Then
there should be no hesitation in applying the trepan a second, or even a third.
The destruction of a considerable portion of the arch of the cranium should
not excite alarm when it is necessary. Solingen says that the Prince of
Orange bore seven applications of the trepan without inconvenience. Spigel
reports a similar case. V. D. Wiell speaks of one on whom it had been applied
twenty-seven times; and, as before stated, M. Toussaint communicated
a case to the academy, in which he used it six times. Besides, every one
knows the facts cited by Blegny, Saviard, and de la Vauguyon, in which,
almost all the arch of the cranium had been removed without destroying
'the patients. Many of the Strasbourg theses contain not less remarkable
cases.
i?emarA;s.'--When several circles of bone are removed for the simple pur-
pose of obtaining a large opening, it is not now customary to leave between
them bony bridges, which it is subsequently necessary to remove with the
chisel, as Hippocrates, Helidorus, Celsus, and many of the surgeons of the
middle age did. The operator should remove them in such a manner that the
circumference of one should reach as nearly as possible to that of the other;
so that if there remain between any more or less projecting angles, they may
be easily removed with the cutting forceps. If a new perforation is to be^
made because the first did not fall upon the effusion or foreign body, it is a*
second operation in which the operator must conduct himself as above directed.
When the seat of the disease is found immediately below the circle, there is
no need of dividing the dura-mater ; but when the extravasated fluids are
more profound, since the time of Glandorp, we do not fear to incise that
membrane. It should, however, be done only where we have good reason to
tlnnk that we shall strike the seat of the disease ; that is, when we observe a
286. NEW ELEMENTS OF,
blackish, livid, or yellow tinge, and a greater or less projection of the external
meninges. This division is to be made by a bistoury held perpendicularly,
commencing at one extremity of one of the principal diameters of the opening,
and carried to the other extremity without going any deeper. It has also
been recommended, that when there exist no fluids between the membranes,
to incise the substance of the brain. Authors cite on this subject a certain
number of facts ; among others, a case observed in the practice of M. Dupuytren,
in which he did not hesitate to sink the bistoury more than an inch deep into
the brain ; such conduct must be but rarely imitated. When the effusion has
its seat in the cerebral substance, how shall we know where to find it ? Is it
not then almost always the effect of an internal cause ? By what sign are we
to recognize its presence, even when it corresponds with the opening of the
bone ? Without doubt, a simple puncture of the brain, even very deep, may
possibly not produce death, or even any other than the slightest consequences ;
but, on the contrary, as it is equally possible that it may, it will always be witb
trembling that a circumspect surgeon will decide to injure thus the substance
of the encephalic organ. In some cases the effusion is separated into different
portions, by bridles, adhesions, or partitions. If this condition be suspected,
the operator must not be content with one circle, but remove two, one on
each side, as has been recommended v/hen operating in the neighborhood of
sutures, or in the course of the sinuses. Wlien trepanning for the extraction
or elevation of a fracture or splinter, the operation requires some peculiar
modifications. First, the point of the pyramid must be applied upon the edge
of the bone that offers the most solidity, and the crown made to cover both
sides of the fracture at the same time. Then, when the effusion is removed,
the attention must be turned to the splinters or depressed fragments of the
bone. All that is proper to be removed should be detached with the pincers,
cutting forceps, or, if necessary, with the chisel, or gouge and mallet. To
elevate parts which are simply depressed, recourse may be had to levers of
different forms. Neither the tripod of the ancients, the triploide elevator of
Scultetus, nor the instrument similar to a cooper's piercer, is any longer in
use. The elevator, with a bridge proposed by J. L. Petit, and the same instru-
ment modified by Louis, are also rejected. All operating surgeons use
the simple elevator, with a steel stock about six inches long, curved ia
the form of an italic ^S*, with a rasp-like roughness on the concave face of
its two extremities, which extremities are flattened like a chisel. It would
even be possible to substitute an ordinary spatula for this instrument.
Often, when there is a fracture, we may, by introducing a chisel or some other
instrument into the fissure, produce a separation of tlie bones sufficient to
allow the escape of the fluids, and thereby render the application of the trepan,
properly speaking, useless. In fractures with considerable separation of the
edges, and in simple fractures of the sutures, of which M. Robert and M.
Goubert have each published a remarkable example, observed in the adult,
the cranium should not be perforated unless the fluids are extravasated under
some other point.
Tlie Dressing is much more simple now than formerly; there is no further
demand in practice for the oils, tinctures, balsams and ointments, of which the
ancients were so prodigal. The sieve-like plate of gold of Auck, and the plate of
lead, recommended by Belloste, are also obsolete. The operators of the preseat
OPERATIVE SURGERY. 289
day content themselves with a disk of fine linen, pierced through the centre
th a thread, which is to keep it out, and which is carefully placed be-
tween the dura-mater and the bone, by means of the meningophylax, of a
spatula, or of a simple probe-pointed stylet; nay, even this may be replaced
by a small fine compress, covered with cerate and pierced with holes. The
middle part should be sunk into the opening in the bone, and the rest made to
cover the internal everted face of the fiap and all the wound. The excava-
tion or purse resulting, is to be filled with rough charpie or lint, which should
be covered by one or more pledgets. Some compresses are then placed over
these, and the whole supported by a bandage, which the surgeon sometimes
applies in one way, sometimes in another; or by a simple triangular kerchief,
the couvre-chef of Galen ; or, still better, an ordinary cotton cap ; or, as
Heliodorus has recommended, a netting of hair, which the Spaniards employ-
under the name of reddizella, and which is used among us to cover the heads
of young girls.
Mynors and M. Maunoir direct that no part of the dressing shall be intro-
duced into the opening of the skull, and that the integuments be brought to-
gether and held in contact by adhesive strips. Blount and Herlich, who give
the same advice, are said to have put it in practice successfully. Others have
gone still further. Job a Meckren speaks of a person, in whom the morsel of
bone had been replaced by a similar piece taken from the head of a dog. M.
Maunoir thinks that we might thus close the opening from the trepan. It even
appears, according to Richter and Walther, that this strange transplanting
operation has been attempted in Germany, not without some success. For
my part, it appears evident to me that the approximation of the edges of the
wound will not prevent the effusion of a certain quantity of fluids between
the dura-mater and hairy integuments; besides, we must most frequently
desire to preserve the solution of continuity open, to give vent to the extrava-
sated fluids, and room for the detersion of the diseased parts. As to M. Mau-
noir's idea, it belongs much more properly to the history of animal engrafting
than to trepanning.
The sequel of trepanning requires no attention which it will be very diffi-
cult for the patient to obtain. The dressings should be renewed every day
once or oftener, if the abundance of the discharge appear to require it.
When the suppuration has dried up, the cerebral affection has disappeared,
and, in fine, when there remains nothing more than the wound from the opera-
tion, the surgeon then occupies himself with its cicatrization, which he should
do by endeavouring to bring together the edges, and treating it as any other
simple wound. This cicatrization presents some peculiar phenomena. Some-
times the circumference of the opening of the bone becomes thinner, and seems
to approach the centre, to confound itself at last with the dura-mater and
integuments of the skull. At other times, especially when the opening is
very large, the edges become blunted or rounded ; some cellular sprouts,
shooting up from the fibrous membrane of the brain, gradually fill the open-
ing, become more and more solid, and ultimately unite wdth the exterior
soft parts ; forming in reality a stopper or plug, of which Duvemey pre-
served a very pretty example. After the cure there generally remains a
depression over the cicatrix, of which M. Serre has reported three examples,
the tliinness of which sometimes permits the movements of the brain to be seen
37"
290 NEW ELEMENTS OF
externally. It has also been recommended, in order to prevent cerebral her-
nia, to keep a convex disk, or plate of lead or other metal, over the depression
just spoken of. To enforce the necessity of this sort of plate, Monro reports
the case of a young girl, who thought she might dispense with one she had worn
for a long time, and who was soon after taken with a cerebral affection, of which
she died at the expiration of five days. As the metals become easily charged
with a great quantity of caloric, it has been feared, and especially with those
forced by their social condition to remain exposed to the rays of the sun, that
they might occasion some serious consequences. Now their place is supplied
by pieces of leather or the like, which are placed like the pads of a truss.
If a necrosed speculum, or part of the bone remain fastened in the healthy
parts, so as to resist the action of the forceps, as has sometimes been observed,
it should, at the instance of J. L. Petit, be entirely uncovered, isolated by
some strokes of the chisel, raised up, and extracted with an elevator or some
other instrument. In young children, the cranium is so thin that it may be
perforated by scraping it with a piece of glass ; or better, with a scraper, as
many authors recommend. The cock's-comb saw, one of Hey's little saws,
should take the place of the crown, if it be only required to remove some pro-
jecting angle of the edge of the fracture. If the necrosis should not compre-
hend all the thickness of the bone, or if the seat of the disease be between the
two tables of the skull, the scraper and the perforator will, without doubt, be
sufficient, and the surgeon will take care not to penetrate to the dura-mater.
But whenever the disease extends to the membranes, it will be dangerous to
follow the advice of Hippocrates ; namely, to leave at the bottom of the open-
ing an osseous lamina as thin as possible, and depend on its exfoliation for
the opening of the passage for the escape of the effused fluids. I would
finally add, that in some cases detergent injections, or any other kind suited
to the indications, will serve to hasten the modification of the pathological
cavity, as well as the rest of the wound, and that there may be some incon-
venience from neglecting to employ them.
CHAPTER II.
7%c Thorax.) Pelvis^ and Extremities.
Next to the cranium, the thorax is the part of the body on which the
trepan has been most frequently applied. The father of medicine used
it, by applying it «ver a rib to open an abscess. It was with the trepan
that Galen removed the carious sternum of a young man that had been in-
jured in wrestling, and in which case he was obliged to penetrate to the peri-
cardium, which was itself injured on its anterior face. Avenzour, Friend
*ays, recommended trepanning the sternum, not only for abscess of the medi-
astinum, but also for that of the pericardium. V. D. Wiell performed thi»
OPERATIVE SURGERY. 29t
operation successfully for a large purulent collection. Colombo, Salius,
Uiversus, and Junker, formally recommend it. Pauli and Solingen say that
Purman found it very useful in two different cases ; J. L. Petit followed their
advice. According to Sprengel, Boettchen recommended its application to
fractures of the sternum, in order to open a way to the elevation of the pieces
of sunken bone. To impress the advantages of it in this case, de la Mar-
tinier e reports that a soldier, wounded at the siege of Philipsburg, in 1734, was
perfectly cured, after having had four large bony plates, comprehending the
whole thickness of the sternum, removed. Mesniere, of Angouleme, was
equally successful with a young patient, who had had this bone broken across.
Almost all the carious portion was removed with a large crown, and the aspcr
rities of the opening were removed with the lenticular knife. Alny followed
the example of Wiell, on a coachman to the king, who had been a long time
affected with an internal abscess, that had opened at the neck. Sedillier
treated a young woman, aged twenty -two years, in the same way, who, as a
sequel of an abscess produced by a blow upon the thorax, was afflicted with
fistulous ulcer, through which he could penetrate without difficulty into the
mediastinum. The carious sternum was found to have concealed a purulent
collection, and the patient was cured in two months. A male adult, in whom
an internal abscess had made its way to the exterior, between the two first
pieces of the sternum, was admitted into the hospital of Rouen, in 1754;
Lecat enlarged the opening in the integuments, scraped the face of the bone
which had been altered by caries, and a few days after applied the crown of
a trepan, which enabled him to convey into the abscess such medicines as
were necessary to the detersion of its walls. Ferrand, of Narbonne, did not
fear in a similar case, although much more complicated, to remove a great
part of the same bone with the trepan, and many of the cartilages of the ribs
with a small saw : his patient recovered. In fine, it was with the same success
that Auran treated a simple caries of the sternum. It is very true that in
this last case the actual cautery has more than once advantageously replaced
the trepan. The fact related by Aymar, of Grenoble, is a conclusive proof
of it ; but Marchetti remarks, that according to his own experience caute-
rizing the neighbouring parts may be very dangerous, and that it frequently
fails of producing a separation of the dead bone. In support of his assertion
I could, if necessary, appeal to a late case in one of the hospitals of Paris.
The cautery was applied, the necrosis did not exfoliate, and the subject died
from the progress of the disease. We may then, with De la Martiniere, assert
that the trepan is a valuable resource in necrosis of the sternum, whether this
necrosis may or may not be caused by some external lesion, or whether it do
or do not cover a purulent collection.
The Method of Operating is governed by the same rules as those applicable
to the perforation of the skull, whether using the crown, the perforator,
Hey's saw, the scraper, or any other part of the apparatus ; only the density
of the bone being less, it is infinitely easier to penetrate into the thorax than
into the cavity of the skull. The internal mammary artery cannot be
touched, unless the disease makes it necessary to apply the instrument with-
out the edges of the sternum. In his first patient, de la Martiniere saw it so
completely isolated, that he thought it right to keep it enveloped in charpie
for some weeks. In another case, the hemorrhage to which it gave rise was
^2 NEW ELEMENTS OF
arrested with simple styptics. I shall say nothing of trepanning, proposed by
some persons for the purpose of getting at the envelope of the heart in peri-
carditis ; nor of that which has been proposed, to enable us to reach the trunk
of the innominata for the application ot a ligature, because I have said else-
where what I think of them.
The Scapula. — There are some other large bones that may be easily tre-
panned. A soldier received the thrust of a foil through the shoulder. The
wound remained fistulous. An ulcer formed in the subscapular fossa, and the
pus could only partially escape by an opening in the scapula. Marechal de-
cided to apply the crown of a trepan over this bone, and by it the patient
was promptly cured. Else, of London, proceeded in the same manner for a
simple necrosis of this bone, and was equally fortunate. Boucher also pro-
fesses to have trepanned the ischium, for the purpose of evacuating an abscess
of the pelvis; and, according to Sprengel,Bilgueris believed to have done the
same to the os coccygis.
Hie Spine. — Even the vertebral column has not escaped the application of
the trepan. Mr. CUne first, and then Mr. Tyrell, have each tried it upon
the rachidian groove, for the purpose of extracting either splinters or blood,
compressing the cord, but the patients died a short time after; and I can
scarcely believe that a surgeon can meet with indications sufficiently precise
to justify the repetition of these attempts with any expectation of success.
The Long Bones. — I have already said that the trepan and gouge are fre-
quently used for removing some parts of the long bones. Boyer many times
made use of it, towards the last of the seventeenth century, to arrest a caries
of the tibia. It is principally in encased necrosis that it is of much assistance.
"When an exfoliation of a certain extent forms and becomes loose in the body
of the tibia, femur, humerus, &c., some fistulas may open from it outwardly,
but, if left to its own exertions, the system can rarely accomplish its expul-
sion. With the assistance of one or more crowns of the trepan, placed op-
posite to each other over certain points of the new osseous sheath that
envelopes it, and a few strokes of the chisel to break up the bridges left ba
tween the crowns, the operator may expose the exfoliation near one of its ex-
tremities in such a manner, that with a pair of strong forceps he may extract
it entire. It is an operation that M. Dupuytren has often successfully per-
formed at the Hotel Dieu, and which many other surgeons have also extolled.
But more ample details on this subject belong to the chapter on Excisions ;
and all the other cases of trepanning not found here, will be spoken of under
the head of the special operations of which they form a part.
OPERATIVE SURGERY. 293
SPECL\L OPERATIONS.
PART I.— OPERATIONS ON THE HEAD.
CHAPTER I.
CRANIUM.
1. Fungous Tumors, — The ligature, cauterization, or excision of fungous or
sarcomatous tumors of the du.ra-mater, would evidently only hasten the death
of the suflferer. Extirpation, the only rational remedy, appears itself to
be but rarely followed with success. In fact, the external tumor is often
but the least part of the disease. After removing it, the operator soon
sees it reproduced, perhaps under a new form. In a word, they have
the common nature of cancerous tumors of all other parts of the body ;
but not being able to present themselves in any other way than through
an osseous opening, it is not possible, as in the latter case, to define, as they
advance, their exact limits. Nevertheless, I cannot see why we should not
attempt to extract them, when every thing indicates them to be circumscribed,
and the disease itself strictly local. In a woman, cured of a cancer of
the breast, who died of a pleurisy at the Hopital de VEcole, in 1824, a scir-
rhus tumor of the size of a pullet's egg, growing from the dura-mater, had
crossed the right inferior occipital fossa, made a slight projection under the
splenius muscle, and was so regularly circumscribed, that it certainly would
have been possible to have removed it entire, if there had been any suspicion
of its existence during life. The operation might be attempted at least for the
fungous tumors of new-born infants, to which Mr. Neagle was one of the first
to call the attention of operators, as well as those which Mr. Abernethy makes
to proceed from sanguineous concretions or diseased lymphatics.
Method of Operating, — The operation in itself has nothing remarkable.
After shaving the head, the surgeon makes a crucial incision of the scalp,
dissects and turns back the four flaps, so as to expose the tumor to a certain
distance from its base ; makes use of the lenticular knife to enlarge the
osseous opening, if he finds its edges thin — should he, however, make use of
the trepan, he will apply it successively at several points around the disease,
so that he may reach even beyond its limits — returning to the lenticular
knife, or using the^ gouge and mallet, he destroys the angles left by the
trepan ; then, with the point of a bistoury, he makes a circle on the non-affected
portion of meninges ; extirpates and removes the whole morbid mass ; and
then follows in the dressing the rules laid down for the same stage in simple
trepanning.
a94 NEW ELEMENTS OF
2. Oiseous Tumors, — Exostosis of the external table of the skull bone
rarely produces consequences serious enough to induce the sufferers to apply
for its removal. But it is not so if they comprehend the whole thickness of
the bone, especially when they jut inward and compress the brain. In the
first case, after having uncovered the tumor, a small saw, the chisel, or the
gouge and mallet, and then the scraper, will suffice to remove it; in the
second, the trepan will be indispensable to isolate it at its circumference and
permit total extirpation.
3. Encephcdocele. — There is no other remedy for a hernia of the cerebrum,
or cerebellum, than a bandage supporting an elastic cushion or ball, properly
applied. All kinds of bloody operations are dangerous, and might probably
produce death, as in the case published by M. Lallement, of the Sal-
petriere.
4. Lupia. — Many persons all their lives carry steatomatous or melicerique
tumors under the hairy scalp, without being sensibly incommoded by them,
or desiring any attempt to remove them. Otliers suffer more or less from them,
and for one reason or another wish at all hazards to be rid of them. The
nature and formation of these tumors are still imperfectly known, and seem
to me to require new researches. At the commencement, there are some
which present the appearance of a small mass, hard, yellow, friable, not
organized, similar to a mass of fibrin, or of blood deprived of its coloring
matter and serum. Whilst growing they soften, commencing at the centre,
and thus transform themselves into a cyst, filled with a substance more or less
fluid, which resembles neither pus nor fat. May we not attribute their origin to
some of the constituents of the blood extravasated ? It is at least certain that
they are not distended cutaneous follicles, as Beclard and S. Cooper assert. If
it were desirable, the ligature might cause them to fall off, of which Boyer re-
lates an example, although it is rare that they can be strangulated at their base.
Bertrand is said to have cured them by passing through them a long needle,
■which he retained like a seton. Bui a cutting instrument is infinitely better,
and should be preferred in every case.
Operation, — When the tumor is very voluminous, and the skin greatly
attenuated, an elliptical flap of the teguments should be removed with the cyst.
Two semilunar incisions are then first made. A transverse incision is then
made outwards from each lip of the wound, so as to form four flaps, which being
turned back with care, allow of the removal of the entire tumor without
difficulty. Most frequently the last two incisions mentioned may be neglected.
Whilst with a hook or a good pair of forceps the surgeon draws the cyst
with one hand, with the other he dissects its external face carefully from the
neighboring tissues with the point of the bistoury. In the ordinary method,
and when it is not necessary to sacrifice any part of the skin, a simple crucial
incision, or T, is recommended ; and every possible caution is to be taken not
to open the cyst whilst dissecting the flaps, which are to be reunited immedi-
ately after the extirpation of the tumor.
Sir A. Cooper pursues another method. He first opeijs the lupus freely ^
empties it by compression between the fore-finger and thumb ; then seizes
the cyst with a crotchet or forceps by one of its edges, dissects it, and takes it
away. An incision being made in such a manner as to leave the posterior wall
of the meliceric purse untouched, M. J. Cloquet immediately lays hold of the
•PERATIVE SURGERY. 295
anterior wall under the right lip of the incision with a pair of forceps, draws
it towards him as he divides its adhesions, which are generally slight, and
operating, as it were, with a single cut, removes the whole cyst. I have
more than once been contented with merely dividing tlie integuments, then
thrusting to the bottom of the wound a strong hook to lay hold of the tumor,
after which it is easy to dissect and remove it. By these three steps of the
simple method, the operation is rendered much more prompt and less difficult
than by the ordinary method. After the removal of the cyst the edges of the
incision bring themselves into contact, and reunion is generally eifected in a
few days.
Hy drocephlus. — The only operation that has been proposed for l.ydrocepha-
lus is puncturing the cranium. Holbrook and Vose pretend to have practised
it, or seen it practised, successfully. Bossi took, in this way, at several times,
six pounds of serosity from the head of a child of eleven or twelve years of
age, who was ultimately cured. Mr. Lyme had recourse to it in 1826, five
times on one child in the space of some months, and each time with some ap-
pearance of benefit, but the little sufferer ultimately died. The Lancet states
that Mr. Conquest succeeded with it twice, and Mr. Geatwood once. Sir A.
Cooper seems to have been partially successful with it. M. Bedor, who has
tried it, also believes in its utility. But the disorder of the brain produced by
hydrocephalus, is commonly too important to be removed by simple puncture.
Still, if the operation be decided upon, nothing is more easily done, with either
a lancet, a bistoury, or a trocar. No other precaution is necessary than to
take care not to injure the venous sinuses. If the operator does not desire at once
to evacuate the whole of the fluid, I think it better to repeat the operation from
time to time, than to leave a canula remaining in the wound, according to the
proposition of Lecat.
CHAPTER II.
The Face,
SECTION II.
The Nose.
Art. 1. — The Rhinoplastic or Taliacotian Operation*
History and ^Appreciation. — In Italy and India it was once the practice to cut
off the noses of criminals. It was thus that Sextus the Fifth treated thieves
and robbers, and the king of Ghoorka the inhabitants of Kistipoor, even
when infants at the breast, in order, as he said, to know them anywhere, and
to be able to apply to their city the name of Nasicatopoor, In all countries per-
sons have been known to cut it off themselves to avoid pursuit, or to tear it from
others to gratify the desire of revenge. Charles II. thought he could not in-
flict a more cruel punishment on the Chevalier de Coventry, who had dared to
speak lightly of two actresses kept by. his king. Frederick II. treated a cer-
tain noble in the same manner, that complained with insolence of having been
296 NEW ELEMENTS OF
enrolled bj fraud. At the approach of the Danes, a great many women and
young girls amputated it themselves, for the purpose of saving their honor. An
abbess and her forty nuns also made use of it when the Saracens presented them-
selves before Marseilles. Who does not recollect the history of the wife of a no-
tary at Paris, who, out of revenge, cut off the nose of another man's wife, of whom
she was jealous ? When we add to these strange mutilations, those which de-.
pend on unforeseen accidents, those produced by small-pox, syphilis, cancer,
scrofula, freezing, burning, &c., it will be seen that an occasion to supply the
loss of the nose may present itself quite frequently. The hideous aspect of
those who have had the misfortune to lose this organ, must soon create a de-
sire to correct as much as possible so repulsive a deformity. Galen, Aetius,
and Celsus speak of the art of mending the nose in their time ; but it was
not until about the fifteenth century that the rhinoplastic operation took its
place among the regular efforts of surgery. P. Ranzano says that the Brancas,
father and son, surgeons of Sicily, who lived in 1442, practised it very suc-
cessfully. Boiani, Celestius, Benedetti, and Bernard treat of it as a customary
remedy. G.Tagliacozzi, who died in 1599, acquired such celebrity from thia
operation, that a statue was erected to him in the anatomical amphitheatre at Bo-
logna. Mercurealis, Fyens, Fallopius, Yesalius, Read, and Gourmelin, speak of
the art of restoring the nose. According to F. de Hilden, Griffon of Lausanne,
was a very able nasifex; and Ambrose Pare says that the court of Henry IIL
"was astonished at the appearance of the Chevalier de Thoan, after his return-
from under the hands of a nose-mender of Italy. Yet, notwithstanding
these testimonials, to which may be added that of Cortesius, Molinelli, Du-
bois, Garengeot, Rosenstern, Moinichen, Leyser, and of Fioraventi, who re-
plied to the incredulous of his time, *' Go visit the Seigneur Andreas, living
at Naples, where every body knows his history, and he will tell you that, hap-
pening to be at the place at the time of his accident, I picked up his nose that
had fallen in the dirt, washed it in warm water, and replaced it ^ well as I
could. Examine this nose and cicatrix well ; listen to what will be told you,
and then see if you can doubt any longer a fact so well proven." Notwith-
standing so much testimony, I say, it was scarcely admitted amongst us as pos-
sible to form a new nose, when the work of Dr. Carpue, published in 181 6, put
the matter beyond further dispute. A Mahratta, who served in the English
army, was taken prisoner by Tippo-Saib. This prince ordered his nose to be
cut off. Having returned to his comrades, Cowajee (the name of the sufferer)
excited the pity of a Hindoo, who refitted a nose in the presence of T. Cruso
and Finley, physicians of Bombay. Pennant made known another case of the
same kind, in 1798 ; and Sir C. Makes affirms that this operation is common all
over the East Indies, where Mr. Lucas says that he performed it about the
time of Hyder-Ali. These facts being transmitted to London, attracted the
attention of Messrs. Lynn, Carpue, and Hutchison, who immediately set them-
selves to examine into the origin of the Indian operation, and the advantages
that surgery might derive from it. Dr. Carpue performed it twice with suc-
cess. M. Gracfe also paid attention to it, and made known the result of his
experience, in 1818. Soon after, some essays of the same nature were made
in France, by MM. Delpech, Dupuytren, Moulaud, Thomasin, Lisfranc, and
Blandin. In fine, Travers, Liston, and Green, in England ; Dieffenbach and
Beck, in Germany, have also endeavored to diffuse the art of repairing the nose
oi'erativb surgery. '2^
Upon consulting the writings of Tagliacozzi, Dr. Carpue, and Professor
Graefe, we will be forced to admit that, in certain cases at least, the new nose
does not differ as much as might be expected from the original. One of the
patients operated upon bj M. Delpech, and who has been seen in Paris, had
not much cause for complaint after this repair. I have seen the subject
whose case M. Ltsfranc published, and I must say, that in him the new
nose was far from presenting all the regularity desirable. On the other hand,
it must not be forgotten that at Paris particularly are to be found false noses,
made of plates of silver, copper, pasteboard, and even wax, which may be so
applied to the face by means of springs, or by securing them to spectacles,
which is still better, that the deformity is almost entirely removed. M. Boyer
speaks of a patient in whom, at first sight, the deception was not perceptible.
Yet a metallic nose will never permit the wearer to blow it, take snuff', or
to use the olfactory function as freely as the mended one.
1. The Italian Operation. — 1st. Tagliacozzi'* s Method, — Although in
Sicily and Calabria there appears to have been many methods, there is one
particularly superior to the others, which appears to have been generally
adopted : it is that of Tagliacozzi ; the only one spoken of in Europe until re-
cent times. The surgeon begins by forming a nose of pasteboard, or of wax, upon
the arm of the patient; applies its anterior face to the nares ; applies it again
to the arm, with its point towards the shoulder, at some suitable spot, and marks
the circumference with ink ; then circumscribes a triangular flap of skin, which
he dissects from its point to its base, by which it is left adhering. A strip placed
below brings together the lips of the wound. After some time the operator pares
oft' the edges of the deformed nose, as well as that of the tegumentary piece of
the arm. Nothing further is then necessary but to bring the bleeding edges
of the two together by means of sutures, and to fix the arm in front of the face
by means of an appropriate bandage. Some rolls of linen are also placed in the
anterior opening of the nostrils. When reunion has taken place, the sur-
geon divides the base of the flap which remains on the face, and makes
the lobule of the new nose. Others are content to make an incision in the
fore-arm, in which they fix the denuded edges of the mutilated nose until it
has contracted intimate adhesions with the skin. Then they have only to cut
and separate a triangular flap on each side from the arm, unite them at the
median line, and thus leave a sort of rapha on the-nose.
b, M. Grasfe^s Method, — In M. Grsefe's method the patient begins by
putting on a laced jacket, which, covers a capuchin or cloak and hood, which
firmly embraces the head. One of the sleeves of this jacket is open before, and
has, near the elbow, four leather straps, and two others shorter near the wrist.
The operator makes raw tlie openings of the destroyed nose ; measures it,
like Tagliacozzi ; marks out and cuts a flap in the same manner ; secures
the arm thus prepared by means of the straps above mentioned, and to keep
the denuded edges of the mutilated nose and the flap in contact makes use
of needles and the twisted suture. After from four to thirty days, the
union will have been completed. The bandages may be then removed,
and the flap detached. After it has once been secured to the nasal partition,
two openings may be made similar to the natural openings of the nostrils,
in which the end of a gum- elastic sound should be placed until the parts have
8
298 NEW ELEMENTS O*
completely cicatrized. M. Gnefe is the only person who has followed — though
he has modified it — the Tagliacotian method; by which he has, he says, suc^
ceeded four times out of five.
2. Indian Methods. — It appears, according to M. Dutrochet and the
above mentioned authors, that there are three kinds of rhinoplastic operations
in India.
a. By means of a Cutaneous Flap from the Rump. — In some countries when
a mighty personage has lost his nose, he procures a slave, whose rump is to be
slapped violently with a slipper until the integuments become swelled. A nasi-
fex cuts a flap, of a form and size sufficient to replace the lost nose, from this sin-
gularly prepared part; applies and fixes it firmly to the nares, which he keeps
open by means of a small cylinder of wood. There is every reason to believe
that this method has been more than once put in practice. It is, in fact, but
amodification of the Italian method, using the skin of another part of the body.
"Van Helmont, in speaking of it, says that a nose formed in this way mortified
suddenly at the end of a year, because the man from whom it had been takea
died at the same moment.
h. By Transplantation. — In the country of the Parias the nobles do not hesi-
tate to clip off the nose of one of their subjects, and put it in the place of their
own, when lost. They succeed so well in this way, say the travelers, that, to
prevent criminals whom they have just punished from repairing their de-
formity, they take the precaution to throw their nose into the fire as soon
as it is lopped off. This is a method of which they were not ignorant ia
Italy, as is proved by the above extract from Fioraventi Molinelli, who affirms
that his father, having received the nose of an Italian in a warm loaf of bread,
•was enabled to readjust it a little while after the execution of the sentence ;
and Leyster says as much of a young man of a high family. Dionis tells that
a robber, having had his nose cut off, ran to a surgeon, who demanded of him
the end of the organ that he might reset it. His comrades went back and
brought it warm to the surgeon, who applied it, and the fellow recovered. In
a quarrel a soldier bit off the nose of his adversary, and threw it in the mud;
the wounded man picked it up, and in full pursuit of the one who had done
him the injury, threw the nose into the stall of M. Gallien, who cleansed
it with some warm wine. The soldier returned, says Garengeot, the nose was
reapplied and secured, and cicatrization took plac€. So that those observ-
ations, that have during a century drawn forth injurious sarcasms on their
authors, may not be altogether apochryphal. In 1742, Dubois being applied
to by a man, the end of whose nose was held by only a thin pedicle, brought
the parts together, and thus obtained, to his great surprise, union by the
first intention. M. Boyer attended a young man, the cartilaginous portion
of whose nose had been almost entirely cut off, and the pedicle supporting
it was scarcely a line broad. This surgeon attempted to produce reunion,
and succeeded quickly and completely. Besides these, there has been in-
voked in support of these transplantations the testimony of Aulaus, who saw
the flesh of a living fowl employed successfully for the cure of a hare-lip ;
of T. Bartholin, who says that a sailor was promptly cured of a wound with
loss of substance, in the hypochondriac region, by the application of mut-
ton, which soon adhered and grew. The experience of Baronioj of Milan,
OPERATIVE SURGERY. 299
contradicted, it is true, by that of Hazard and Goliier, but strengthened by
that of Duhamel and Hunter, proving that the skin from the sides of an animal,
transplanted from right to left, or applied in the same situation upon other ani-
mals, adheres and continues to live. The case of the young men of the north of
Germany, who, as an evidence of their intimate friendship, exchanged witli
each other a flap from the anterior face of the fore-arm; and finally, those
cases of complete separation of the fingers from the hand, reported by Heister,
Pouteau, Thompson, Bayley, M. Lespagnol, M. Wigorn, Balfour, and many
others, cited by Percy, &c., go to establish this point. If it be admitted that
many of these cases should be numbered -among the stories of old women, it is
difficult to have any doubt of the numerous and well-authenticated cases,
recently related by Hoffaker in Germany, Piedagnel, Berard, junior, and
Barthelemy, in France ; cases in which portions of the nose, ears, lips, fingers,
&c., have been seen completely or almost separated from the living tissues, re-
applied to the wounded surface, contract adhesion and reassume vitality. The
six examples of Hoffaker epsecially, leave not the least doubt in this matter ;
and M. Layraud saw a man whose two middle fingers, cut by a single stroke so
nearly through that they held but by a small strip of skin on the palmar face,
were yet perfectly recovered by being brought into reunion, and held so by
small splints.
c. With the Skin of the Forehead, or the Method of the Koomas. — By the method
generally preferred in England and France, the surgeon commences, as in the
preceding, by forming a nose of wax or pasteboard, which he then spreads
upon the forehead with the point downward. Its circumference is marked
with some coloring matter. The operator then dissects the flap thus traced,
taking care to leave at its base a small prolongation destined to replace the
nasal partition; turns it downward by detaching it as low as the malar bones ;
twists the pedicle so that the cuticular surface of the flap may be outwards ;
cuts and regulates the form of the nares; unites their bleeding edges with
those of the flap; secures, them in contact by means of a composition of
terra japonica, or by the suture ; brings down the middle pedicle upon the
upper lip, and fills the openings of the new nose with small compresses
rolled into cylinders, pieces of the barrels of quills, or gum-elastic sounds.
Remarks, — The East Indians scarcely ever use the suture. Dr. Carpue
preferred it; and M. Delpech, who performed the rhinoplastic operation
twelve times, says that it should never be neglected, and that the twisted
suture should be preferred. Tagliacozzi has well remarked, that the skin,
once separated from the parts which kept it extended, contracts, and that it
is important to give the flap a greater size than seems necessary for the new
organ that it is about to form. The wound of the forehead, at first very large,
contracts rapidly, and leaves a cicatrix much smaller than would be expected
immediately after the operation. Blandin also pursued this method with
the two patients on whom he recently operated. The one I saw has done
very well. His nose is somewhat large and round, but not much deformed,
firm, and of a very regular continuity with the forehead, as well as with
the cheek, by two grooves, the right of which being deeper than the left,
gives it an evident inclination in that direction. Instead of dividing and
fexcising the pedicle after adhesion has taken place, M. Blandin denuded
the root of the flap, and united it with the wound of the nose, which he pro-
Ji^
500 NEW ELEMENTS 0^
longed upwards by loss of substance for this purpose expressly. In this
manner the circulation was never stopped, and' the form of the new organ
became more regular between the two orbits. His second patient, although
attacked with erysipelas and delirium, was finally cured, and has a nose still
more regular than the first. M. Lisfranc contented himself with adhesive
straps instead of sutures, in the case of his first patient, Eval. In order to
lessen as much as possible the- effect of the twisting of the flap, he extended its
ftpex three lines lower down on one side than the other; and also, to avoid
cutting the pedicle at a later period, he united it by two lateral incisions made
on the sides of the natural nose. Uhion took place at first only on one side,
and the suture became necessary on the other. In one case treated by M.
Lisfranc, everything announced a happy termination, when another disease^
foreign to the operation, put an end to the hopes of the surgeon. "*■*
4th. French Method. — M. Dieffenbach's operation consists rather in the
mending of the nose than the formation of a new one. He dissects up and
fashions the sides from the mutilated nose, places small flaps or strips, which
he gets from the neighborhood, between them to fill up the void, and then
unites the whole together by fine needles and the twisted suture. The pas-
sages in Celsus, Galen, and Paul of Egina, apparently relating to the rhi-
noplastic operation, indicate, I think, this method of operating. It was also
on different parts of the face that they sought flaps to cover the denuded parts.
Celsus even says, that if the operator takes the precaution to make long ver-
tical incisions near the ear, it then becomes much easier to bring the skirt
towards the median line. It was by making use of the neighboring tissues
that Franco succeeded, as we shall see further on, in restoring the cheek of
one of his patients. We may add, that qne rhinoplastic operation of this kind,
performed in 1820, by M. Larrey, was entirely successful; and that the
soldier was presented to the faculty of medicine, when I had an opportunity of
examining him. Among his cases, M. Dieffenbach insists particularly on that
of a young girl, in whom the vomer, ossa malarum and vertical lamina of the
ethmoid bone had been destroyed by scrofula ; whose nose, instead of being
convex, was so sunken as to present a hollow. Many incisions, much nearer
one another on the side towards the forehead than on that towards the upper
lip, permitted him to bring out this semblance of a nose, and also to raise up
its sides. Other transverse or semilunar incisions facilitated the union
of the bands made by the first incisions, whilst a small flap was borrowed
from the lip to form the partition. Several needles were afterwards applied
in various directions, and by the assistance of some small patchings, which
several accidents rendered necesssary, M. Dieffenbach ultimately succeeded
in giving to the nose of this patient a passable form and regularity.
5th. Jlelalive Value. — Of every method, that of the Koomas, besides being
evidently the most painful, has the great disadvantage of correcting one de-
formity only by producing another. As a consequence, the forehead neces
sarily becomes the seat of an indelible cicatrix, which is sometimes very large.
In those persons whose eyebrows meet over the median line, or who have the
hair of the head very low down, the base and another point of the flap may
remain covered with hair after the cure, without the possibility of pre-
vention. Few men would consent, at this day, to sell their noses to a rich
man, who would wish to obtain one in the place left by his own. Should that
OPERATIVE surgery/ ^01
which has been said of this species of aDimal grafting be true, the Parian
method could only be put in practice in cases analogous to that spoken of by
Garengeot. The Mogul method, the strangest of all, is subject to the same
remark. The distress which would result from the necessary union of the
two individuals until the base of the borrowed flap could be divided, will doubt-
less prevent the adoption of this method. As to M. Dieffenbach's ideas, it
would, I think, be as injurious to adopt them exclusively as to reject them en-
tirely. Although applicable to cases of mere deformity, or where the loss of sub-
stance is small, it will not suffice when there is an almost complete absence of
the organ. A patient on whom MM. Lisfranc and Serre performed it, and
whom I have seen at La Pitie, obtained very little benefit from it. And
M. Marjolin told me that he had seen a man operated on in this manner at
Rouen, who had not been more fortunate. Every thing seems to go on well
for some time, but as the cicatrix hardens the tissues contract, and the new
nose becomes more and more flat. It is, then, Tagliacozzi's method, or rather
M. Graefe's modification of it, which seems most rational. It is there that
we must seek the general method, whilst the others may be reserved for par-
ticular cases. The method of the Koomas, however, is the one which in our
day has been the most frequently and completely successful.
When the bone has not disappeared, but only the lobe and the cartilages
have been destroyed, the rhinoplastic operation may remedy in a great mea-
sure the deformity. In other cases there is much reason to fear that the new
organ will reduce itself ultimately to a sort of stump, and remain always
flabby, sinking in like a piece of linen from the pressure of the atmo-
sphere. When the integuments of the forehead are used in the formation
of the nose, it is necessary to leave the twisted pedicle large enough to
preserve the circulation of the part. Before separating it from the root of
the nose, and excising that portion above the neighboring surfaces, the opera-
tor should wait until the new tissues in front are firmly united. Instead of a
roll of linen, a ball of charpie, or a gum -elastic canula, to maintain the open-
ing of the nares, I prefer a plate of lead curved into a ring, which may, at the
same time, also form a mould or pattern for the formation of the nose. M.
Delpech seems to me to have very well combined every step of the operation.
Although not absolutely necessary, the modification of M. Lisfranc, or that
of M. Blandin, which is but an improvement of the other, has its advantages.
In taking the teguments from the arm I do not know whether it will be more
advantageous to follow the precepts of the surgeons of Sicily, or to imitate
the professor of Berlin. Finally, this operation is one too little used to pre-
vent each one from pursuing his own method ; and the circumstances, too,
that require it, are too different not to demand that the manuel of each ope-
ration should be left to the particular ingenuity of the operator,
\Art, 2. — Other Operations on the Nose.
1st. Excision of Tumors. — The removal of tumors from the nose does
not differ much from the same species of operation on other parts. I will,
however, remark that the lobe of this organ being much thinner than one
would imagine at first sight, it is very easily cut through, and that its perfora-
502 NEW ELEMENTS OF
tion is almost necessarily followed by a fistula difficult to cure, on account of
the atmospheric air passing through it.
2d. New Operation. — In describing the partition of the nose, Bichat indi-
cated the possibility of an operation which, until very lately, remained apiece
of theory, but which M. Rigal has just reduced to practice. Whilst resting
against each other at the median line, the cartilages of the lobe leave between
them a small groove perceptible even through the skin, which permits us to
separate them, and to penetrate as far as the bony partition of the nostrils
without opening these cavities. A cancerous tumor, developed under
the anterior nasal spine, and which had gradually extended forwards and
downwards, and sideways to the alae of the nose, had yet scarcely al-
tered its tegumentary covering. Two incisions united before, turning back-
wards and outwards, so as to resemble a Y reversed, having dug it out
laterally, it became easy, by means of a transverse incision, to detach it below
from the upper lip; then, by separating the two lips of the first incision, to
reach the cartilage of the partition, its anterior edge was excised, and thus the
whole morbid mass was removed. The sides of the division were then brought
together, and the cure was not attended with any thing unpleasant, except that
the cicatrization drew the tissues backward, and slightly flattened the alae
and apex of the nose.
i Sd. Occlusion of the Nostrils. — In consequence of confluent small-pox,
syphilitic or other kinds of inflammation, the rhinoplastic operation itself,
and, in fine, of all lesions which may alter the form of the nose, the anterior
opening of this organ is liable to be closed, or at least contracted so far
as very much to impede respiration. For all inconveniences of this kind
there are three orders of remedies: 1st, dilatation; 2d, incision; 3d, ex-
cision. It is rare that simple dilatation will suflice; it is, besides, only
adapted to cases of stricture or contraction, and not to those of complete
closure. Incision, in its turn, almost always requires the assistance of dila-
tation. Excision becomes useful if tubercles or morbid projections require
removal. If the opening be simply contracted, it should be cut in many
eccentric rays, and more or less deep according to the degree of the disease.
When it is entirely closed, a straight bistoury must be plunged into the place
which the opening naturally occupies. By this means the operator makes
an antero -posterior opening, the sides of which, I think, it will be well to incise
at two or three points. As it is necessary at every hazard that these sides
should heal separately, and in the position first given them, it seems to me that
we shall better attain this end with a plate of lead rolled into a ring, or of such
other form as may be appropriate, than with the dilating bodies commonly
employed. This is, however, a very simple operation, on which I shall not
dwell.
Rhinoraplua, or the simple suture of a cleft of the wings, or any other part
of the nose, once successfully performed by M. Roux, being but a step of the
rhinoplastic operation, or governed by the same rules as cheiloraphy, need not
be discussed in this place.
OPERATIVE SURGERY. 50S
SfeCTION II.
The Apparatus of Vision.
Art, 1. — Lachrymal Passages.
§1. Anatomical Remarks,
The nasal duct, formed internally by the posterior border of the ascending
apophysis, the anterior third of the os unguis, and, quite low down, by a little
lamina of the inferior spongy bone ; without, forward, and behind, by the
maxillary bone and its cornet ; then a little by the hook of the os unguis ; is
from three to five lines long ; cylindrical towards its middle ; a little longer
antero-posteriorly than transversely in its superior part ; terminating below
in a funnel-shaped orifice, and has but little solidity, exceptin the internal and
anterior third of its circumference : whence it follows, that in attempting to
pass through it it is extremely easy to break its other wall, and penetrate
either into the nasal fossa or into the maxillary sinus. The lachrymal groove
seems, in prolonging the internal wall towards the corresponding orbitary
apophysis of the frontal bone, to become more and more superficial as it goes
upward in the orbit, but presents, on the contrary, in the lower part of its
extent, two lips easy to be distinguished : one, anterior, belonging to the
ascending apophysis; the other, posterior, formed by the external crest of the
OS unguis.
The fibro-mucous membrane which lines the nasal canal, and to which it
fidheres but very feebly, becomes much stronger and more complicated in the
groove, where it takes the name of the lachrymal sac. Here the straight
tendon of the orbicularis muscle crosses its antgrior face at a right angle, so as
to divide it into two equal parts ; one, superior, over which this tendon sends
a fibrous expansion, known under the name of the reflected tendon of the
naso -palpebral muscle; the other, inferior, covered outwardly by cellular
tissue, the limits of which it is very important to know. The triangular space,
limited above by the straight tendon, below by the rim of the orbit, and out-
wardly by a vertical line which touches the external edge of the caruncula la-
chrymalis, always comprehends this last portion. It is only covered by some
fleshy fibres, a little laminated tissue, and the integuments of the greater angle
of the eye. As it is badly supported by the surrounding tis ues, it yields
easily to the action of the causes which tend to dilate it, and thus becomes the
ordinary seat of the lachrymal tumor and fistula.
Surrounded by a small circle, dense and elastic, but not cartilaginous, the
lachrymal puncture has a direction completely vertical, and forms a very evi-
dent angle at its continuation into the lachrymal duct, properly so called. The
latter, which traverses only the anterior fifth of the free edge of the eye-lids, oc-
cupies more particularly its posterior part. Consisting only of the mucous mem-
brane, it is very thin and superficial in its poster© -superior half; whilst the rest
of its circumference, consolidated with the lid, presents anteriorly and below a
texture much more solid. It is this anatomical disposition which requires us
to give the instrument, first, a perpendicukr direction, .then to incline much
304 NEW ELEMENTS OF
more towards the nose than towards the eye, when we desire to pass it through
the duct itself. At their entrance into the sac these ducts are sometimes
separated by a small projection, a kind of spur; very often, however, they are
confounded in the same opening.
Taken all together, the lachrymal sac and the nusal canal present a double
curve, somewhat resembling that of an italic /; that is, that the first is slightly
convex backwards and inwards, and the second convex in a contrary direction ;
so that to cauterize it from the upper eye-lid, it is necessary to take care,
whilst the stylet traverses the sac, to incline its inferior extremity rather
forwards and outwards than in a contrary direction, and that to pass through
the nasal canal, it is better, on the contrary, to push the instrument backwards
and inwards.
Thus, as every one may have observed, the axis of the nasal canal, in its
relation to the superior orbitary projection, presents numerous variations.
The depth at which it should be sought in tlie orbit presents as many more.
In those subjects on whom the root of the nose is flat and broad, it seems to
be thrown outwards and sensibly shortened; when the ossa-malarum are
very near each other at their internal face, it can, on the contrary, be only
reached by going much nearer the median line; when the forehead is very-
prominent, and the maxillary bone very much dilated, the lachrymal duct is
at some distance from the posterior face of the orbicularis tendon, whilst it
seems to pass a little in front of this tendon in those who have the canine fossa
very deep and the forehead depressed. To discover it through the soft parts,
the operator may, like M. Lisfranc, follow the inferior edge of the orbit, be-
ginning from the cheek bone, and feeling with the pulp of the index finger
until he feels, near the root of the nose, the anterior groove of the lachrymal
sac, or by carrying the nail of the finger over the inferior and internal edge
of the triangular space described above, after having by gentle pressure
dissipated the engorgement of the soft parts. The sort of valve or diaphragm
which contracts the inferior extremity, is commonly open only in its posterior
half. Its orifice is six or eight lines deep in the nose, at the summit of an
excavation, limited anteriorly by the base of the ascending apophysis of the
maxillary bone, and inwardly by the concave face of the inferior spongy bone.
As this excavation is a little longer from the lachrymal valve before than
behind, it happens that it is sometimes very difficult to pass through the lower
part, if the surgeon be ignorant of this arrangement. Sandifort, Callisen, and
others, speak of concretions, small calculi that entirely obliterate the nasal
canal. M. Demours has met with abnormal bands. M. Taillefer described
a membranous fold occupying the superior third, the free edge of which, hang-
ing downwards,was produced in many small filaments,which fixed it to another
point of the canal, so that a stylet carried from below upwards was evidently
arrested by this anomaly. Further, some have seen the canal entirely closed.
Morgagni relates a case of its being double ; Jurine and Dupuytren have also
met with this arangement.
§ 2. Obstruction^ Tumor.
Stenon, Valsalva, Stahl, and a veterinary surgeon quoted by Morgagni,
had already attempted to explore the route of the tears by means of probes very
fine and more or less appropriate, when Anel fixed public attention on this
OPERATIVE SURGERY. g^5
point in 1716. Accox'ding to his partizans, this operation is indicated in
tumor, fistula, simple obstruction, obliterations more less complete, stricture
partial or general, ulcerations, and chronic inflammations of the canals,
sac, or puncta, as well as of the duct. It may be used for the introduction
of threads, tents of ditterent kinds, injections of medicated or other fluids,
and may be performed either from the lids or from the nose.
1. AneVs Method, — Anel had two methods of treating affections of the
lachrymal passftges. Sometimes he attempted to remove the obstructions by
means of a very fine stylet, slightly enlarged at one of its extremities ; at
other times, by means of detersive or otherwise medicated injections.
Injections. — For injecting he invented a small syringe of silver or gold,
holding three or four drachms of fluid, terminated by a very fine tube, to the
point of which was adapted a copper pipe finer still. The patient is placed
fronting the strong light of a window. With the left hand for the left, and the
right for the right eye, the surgeon moderately depresses the lid, and brings
forward its free edge. With the other hand he manages the syringe ; places
the point perpendicularly in the punctum ; in this direction sinks it in about
one line, then turns it horizontally; sinks the little tube of copper about three
or four more lines ; then with the thumb upon the ring at the posterior extre-
mity, and holding the body of the instrument between the index and middle
fingers, gently forces the medicated fluid into the lachrymal sac. The operator
should prefer the lower punctum in this operation, because by the upper, it
would be less convenient and less sure. The first time the patient finds it
difficult to bear. It is followed in some cases by considerable irritation. It
IS only after being several times repeated that the patient becomes accustomed
to it, and that it produces only slight pain.
• Catheterism. — When injections will not succeed, or will succeed o::ly
partially, in passing into the nasal fossa, Anel advises recourse to the probe.
The operator places himself behind the patient ; turns the lid slightly outwards
and upwards; takes hold of the probe like a pen; places the button perpendi-
cularly over the orifice ; then inclines the base outwards and upwards, as if with
an intention of carrying it to the external orbitary apophysis ; sinks it gently;
with the other hand draws the nasal portion of the lid inwards, and towards the
internal orbitary apophysis, as if to give it a vertical direction ; then pushes on
the instrument in this direction, taking care at the least obstacle to draw it
back and change its course a little, either forwards, outwards, backwards, or
inwards, until it pass into the corresponding nostril ; after which it is with-
drawn to give place to injections.
The introduction of this probe is a delicate operation, and very fatiguing to
the patient. It requires, on the part of the surgeon, an exact knowledge of*'
the anatomical arrangement of the parts concerned. The smallest fold, na-
tural or morbid, of the mucous membrane, suffices to arrest the instrument,
which, in consequence of its fineness and flexibility, is really incapable of over-
coming the slightest resistance ; yet it continues to be described and used, be-
cause some surgeons, as we shall see hereafter, have applied it to the cure of
fistula lachrymalis.
2. Laforest^s Method. — Seeing that injections and catheterism, after the
manner of AncI, were sometimes very difficult to be practised, and at the same
time believing in their utility, Laforest and iVllouel, following Bianchi, and
306 NEW ELEMENTS OF
the veterinary surgeon cited by Morgagni, and supported by a passage from
La Faye, invented almost at the same time a method of penetrating the
lachrymal passages through the nostrils. To accomplish this object, Laforest
made some small solid probes curved in an arc of a circle, and hollow probes
of the same form, conical, open at their points, and terminated below by a
pavilion furnished with a small lateral ring, proper to fix the instrument to
the side of the nose during the intervals of dressing. The sound, passed from
below upwards into the nasal canal, was intended to remove the obstructions.
After this was withdrawn, the hollow sound took its place, and served for the
injection of suitable fluids by means of a small syringe.
Remarks. — Like AnePs, the method of Laforest has been but rarely used for
the purpose intended by its author; but other surgeons have attempted to
combine it with certain steps of the operation for fistula lachrymalis. M. Briot,
of Besancon, for example, is in the habit of using it constantly, and, as M.
Vesigne says, with the greatest advantage. These injections, either from
above or below, are means worthy to be kept in use. It is evident, in fact,
that by applying medicated fluids to the seat of the disease, we may often
render a more serious operation unnecessary. But it may be asked, if we
may not accomplish the object by still more simple means ; if fluids carried
into the nose by means of fumigation or inspiration, would not traverse the
lachrymal passages in the same manner ? Moulac and Louis are said to have
used this application successfully. Recently Mr. Mackensie has formally
recommended, as a result of his own observations, to reject all syringes,
probes, and canulas. It is sufficient, in his opinion, to throw once or twice a day
some drops of the medicated fluid into the ocular lake, that is, the greater pal-
pebral angle, and the puncta will absorb it and direct it through into the nose.
§ 3. Fistula.
When the lachrymal tumor is ulcerated, or when it resists the employment
of Anel's, Laforest's, Louis's, or Mackensie's plans, the general or local
antiphlogistics, formally recommended by Guerin and recently brought into
favor by Gama and Lisfranc, as well as anti-syphilitic, anti-scrophulous, and
other similar treatment, it is admitted in practical surgery that the operation,
properly so called, must be had recourse to. Yet it must not be forgotten that
Maitre-Jean saw two fistulas of the most serious nature spontaneously cured ;
that M. Demours rarely uses a cutting instrument in treating it; that the
ancients, with their farrago of escharotics, styptics, caustics, and inefficient
pharmaceutical compositions, also cured some cases ; and finally, that in our own
days it has been seen to disappear in those who have only been treated with local
bleeding and low regimen. This will be the more important as it will enable
us to comprehend the fact, that by every plan proposed, the fistula lachry-
malis has been cured. As it sometimes cures itself, it is not to be wondered
at that compression, which was formerly praised by Avicenna, and for the
accomplishment of which J. Fabricius, Hunter, and de la Vauguyon, have
invented very ingenious bandages ; that tents of charpie covered with oint-
ment more or less active, and that leeches and emollient cataplasms have
favored the cure in many cases. Lately (November 1831), a male adult
was sent to me at La Pitie, by M. Grenier, to be operated upon for fistula
OPERATIVE SURGERY. 307
lachrymalis. It was easy to prove the existence of the disease,which was of some
months standing. Whilst I was preparing a canula, the fistula closed, and
has not since reappeared. If leeching or any other medication had been used,
this cure would inevitably have been attributed to it, and it is probable that it
is in such cases fhey have sometimes been successful, Messrs. Mortehan,
Caucanas, &c., have reported similar facts. Be this as it may, science now
possesses an almost infinite number of methods of operating, adapted to the
almost certain cure of this affection. To reduce the examination of these
various methods to order, I shall divide them into five varieties or kinds.
In the first, threads, tents, or some other foreign body is made to pass
through the natural opening; in the second, the lesion is to be caused to dis-
appear by means of mechanical dilators, introduced through the accidental
opening -, in the third, a metallic canula is left in the nasal canal ; in the
fourth, the disease is treated by means of the cautery ; and in the fifth an ar-
tificial passage is formed for the tears,
1st. IHlatation of the Natural Passages.
a. Mejeari's Method. — Observing that the employment of injections, and the
removal of obstructions in the lachrymal passages with the probe of Anel, only
destroyed the disease for a while, Mejean conceived the idea of applying to
the nasal canal the treatment by dilatation, for a long time in use for stricture
of the urethra. By means of a very fine probe, with an eye to receive a
thread at its superior extremity, this author explores the passage, like Anel;
endeavors to engage the head of the probe in the hollow of a grooved director,
inserted for this purpose through the lower meatus of the nostril, and draws
it out with the thread which it carries ; this forms a kind of seton, the two
extremities of which he fastens to a pin, which he fixes in the cap or hair
of the patient. After a day or two he attaches two bits of charpie rolled up
in the form of a tent, and covered with cerate or medicated ointment, and
to which another thread is attached at its lower extremity. This tent is thus
drawn from below upwards through the nose, into the superior portion of the
lachrymal sac. It is every day renewed, and enlarged by adding a small
portion of charpie. To extract it, the dresser uses the thread suspended in
the nares, and which between the dressings remains fixed over the cheek by
means of a small patch of taffeta.
By this method the treatment may continue for two, three, four, or six
months. The cure obtained is rarely permanent. Out of twenty patients
treated in this way, there were not more than three or four, according to the
authors of the period, in whom the disease did not reappear after some months.
Besides which, Mejean- s method presents two difficulties not always easily
overcome. The probe often becomes embarrassed in the lachrymal sac, and
it is not until after long and fatiguing attempts that it can be engaged in the
nasal canal. Unless the surgeon has great experience, he will often find it
very difficult to bring the groove of the sound and the eye of the probe together
at the inferior horn, or to seize the latter so as to bring it out.
b. FalluccPs Method. — Pallucci thought that, by introducing a small hollow
sound, very flexible, in the place of Mejean's probe, it would be possible to pass
through this sound a cat-gut cord so fine that the patient could force it through
308 NEW ELEMENTS OF
bj blowing his nose ; which was then to answer the same purpose, and be
nsed in the same manner, as the thread in the preceding method. But it is
evident that this modification complicates tlie operation of the French physi-
cian, instead of simplifying it, and that it would be much easier to get through
the lachrymal passages with a probe than with a canula.
c. Process of Cabanis. — Cabanis, a physician of Geneva, has proposed a
very ingenious instrument with which to take hold of the probe of Mejean at
the inferior meatus ; it is composed of two narrow blades, susceptible of gliding
upon each other, pierced with a number of holes, passing through the upper
piate, but only penetrating to a certain distance into the lower. This instru-
ment is passed under the inferior maxillary cornet. By proper movements,
the probe is engaged in one of the holes of the united blades; then these are
made to slide on each other, one forward, the other backward, that the holes
may lose their parallelism, and the probe become pinched. Cabanis also
recommends that, after the thread has been drawn out at tlve nose, its extremity
should be attached to a small flexible sound, which could thus be carried with
certainty into the inferior opening, and, after the manner of Laforest, into
the nasal canal. M. Bermond, of Bordeaux, who reproduced this idea in 1825
and in 1827, has correctly remarked, that to avail one's self of it, it is suf-
ficient to get the conducting thread of Mejean out by any contrivance. As the
instrument of Cabanis is not indispensable, and as the introduction of a probe
and thread b}^ the punctum counterbalances the advantages that could be
subsequently drawn from it by the introduction of a sound, after the manner
of Laforest, surgeons have not adopted these modifications.
d. Guerirvs Method. — Having observed that a thread left in the superior
lachrymal ducts, excoriates, and sometimes tears the palpebral orifice, Guerin
recommen.iS that the tent of Mejean should be brought up to this point. M.
Desgranges, who found it better to seek the extremity of the probe in the nose
with a small blunt hook than with the grooved sound or the plate of Cabanis,
adopted this idea, which Dr. Care has recently endeavored to diffuse.
e. Process of M. Care. — The process of this physician consists in passing
from below upward, with Mejean's instruments, a tent of raw silk composed of
three, four, or six strands, as many in fact as can be passed, and with them
dilating the conduits and puncta. One of its extremities is afterwards fixed
upon the forehead of the patient, when it has been passed from below upward,
or on the side of the nose, if in a cfontrary direction. A small ball is formed
of the other extremity, which may be fastened in the hair. M. Dubois appears
to have followed this course several times, and I have seen it used once at the
Hopital de Perfectionnement, by M. Bougon. Its partizans think that a tent of
this size is not liable to tear the punctum, and that the dilatation of the
lachrymal duct which it produces is one of the best means of curing the
disease of the canal itself. We may condemn it, in my opinion, as only
dilating the healthy parts, without acting directly upon the diseased point of
the organ through which it passes, and also of deforming and paralysing the
puncta and their duct§. Reason appears to me altogether against the method ;
and lil have not learnt that experience has pronounced in its favor, I think
that it should not be preferred. I cannot even see any thing that should
induce us to try it.
OPERATIVE SURGERY. 309
2. Dilatation through an Accidental Opming,
a. Process ofJ.L. Petit, — Petit was the first who fully showed that the ope-
rator should endeavor to establish a passage for the tears through the natural
channel, rather than create a new one. His method may be considered as the
mother of all those of the present day. The assistant, placed behind the
patient, draws tlie temporal angle of the lids outwards to steady them and
straighten the tendon. The operator then caiTies the point of a bistoury into
the sac, below the tendon of the orbicularis muscle ; makes an incision about
six lines long at the greater angle of the eye; slips in the place of this instru-
ment a grooved sound, which he pushes with more or less force into the nose,
in order to destroy the obstacles that oppose the passage of the tears, and
introduces by its aid a tent or conical bougie of wax, the extremity of which
must be more or less swelled, and secured by a thread. The bougie should
be changed, or, at least, cleaned every day, until the canal gives no further
signs of suppuration; that is, for two, three, four, five, or six months. J. L.
Pe'tit afterwards thought that he could dispense with the grooved sound, by
making a groove near the back or upon the anterior face of the bistoury, which
would serve to direct a blunt probe ; but as this rendered it necessary to
have a particular bistoury for each side, operators have generally neglected
this supposed improvement.
b. Process of Monro. — The reputation that Petit's method at first gained
did not prevent some surgeons from combating it or exposing its defects.
According to Monro, it would be imprudent to open the sac without supporting
its external or anterior wall. It was for this purpose that he proposed to pass
a small probe through the inferior lachrymal punctum to distend it, and to allow
of its being opened without wounding th-e posterior wall. Monro also recom-
mends that the canal be forced with an awl rather thaji a probe ; that the open-
ing of the sac be continued upv/ards with the scissors, at the risk of dividing
the straight tendon ; and that, instead of the bougie of Petit, the operator should
use a tent of charpie or cat-gut. These precepts are now disregarded.
Tiie wounding of the sac behind, besides being easily avoided in the common
method, is not dangerous, whilst tliat of tlie tendon of the orbicularis muscle
is always so, and the employment of an awl may, by a slight misdirection,
produce false passages.
c. Pouteau's Process. — Introduced from above downwards, the bougie ulti-
mately produces in the great angle an ulcer, the edge of which turns inward,
and consequently leaves a cicatrix strongly depressed. Having attempted
Mej can's method in vain for a young woman, and not daring to propose an
incision of the sac, after the manner of Petit, Pouteau resolved to carry his
bistoury between the straight portion of the edge of the inferior lid and the
caruncula lachrymalis, so as to penetrate into the nasal canal without touching
the skin. There followed, says the author, only a slight ecchymosis, because
he made the incision small. No person, however, has imitated him, from
the fear of irritating the conjunctiva. Besides, the inconveniences for the
remedy of which Pouteau recommepds it, have been so much reduced in
modern surgery, that no one now takes notice of it.
d. Process of Lecat. — After having incised the sac, like Petit, Lecat
310 NEW ELEMENTS OF
uses tents of charpie, which he carries from above downwards through the
nasal canal bj means of a cat-gut or Mejean's probe. In this respect, he is
the first who has endeavored to combine Mejean's method with Petit's ; but
as his tent must produce the curling down of the edges of the wound, which
is so much tlie subject of apprehension, the profession has never paid great
attention to his precepts.
e. DesauWs Method. — To obviate as many as possible of the inconveniences
of the preceding processes, Desault modified almost all of them, and com-
bined several. Bj his method, the incision of the sac is made only of two or
three lines in extent. A grooved sound is then used to overcome the
obstruction in the canal. Then a cylindrical stylet or probe takes its place.
A small silver canula, from ten to twelve lines long, conical, and furnished
with a ring on the side of its pavilion, is carried from above downwards, into
the nose by means of the stylet or probe, which represents a conductor, and
which is then withdrawn. The thread is then passed down, and its extremity
brought out by the patient's blowing his nose, after which the operation is not
different from Mejean's.
/. M. Boyer'^s Modification. — To make as mucli of the thread descend
through Desault's canula as may be required, we may imitate M. Boyer,
and use a small probe three or four inches long, bifurcated below, and
terminated with a ring above ; and afterwards, to extract this thread from the
nose, we may use the little hook of Guerin, or the dressing forceps, or trust
to the patient's forcing it out by blowing his nose. If none of these will serve,
it may be left in that organ, as the mucosities of the schneiderian membrane
will almost always bring it out in the course of twelve or twenty-four hours.
If, however, it should be otherwise, injections thrown with some force through
the opening in the lachrymal sac never fail to bring it out.
g. Method of Pamard. — Opposed by the difficulties of extracting the liga-
ture by Desault's method, Pamard, of Avignon, and Giraud, almost simul-
taneously made an improvement which surgeons of the present day still prac-
tice. It is a small elastic probe, made of a watch spring, with a button at
one end and an eye at the other. The head of this spring is passed into the
canula, and when it has arrived under the inferior horn, its elasticity naturally
directs it either to the opening of the nares or under the lobule of the nose,
where it may be reached with the fingers, or a pair of dressing forceps.
M. Roux scarcely ever uses any other method, and it cannot be denied, that
he most frequently completes the operation for fistula lachrymalis with great
celerity; yet, when the spring is not well tempered, and even sometimes when
it is most perfectly finished, its extremity is disengaged with much difficulty
from the inferior meatus. Whence M. Boyer feels himself bound to adhere
to the method of Desault, although he practices in the same establishment
with M. Roux, and although he has frequently employed the spring needle
of Pamard.
h. Process ofJurine. — In order to leave the least possible deformity in the
angle of the eye, Jurine performed his operation with a small trocar of gold,
the canula of v/hich was pierced near the point. He passes it into the
nose, and then, after withdrawing the 'stylet, passes by its canula the spring
of Pamard. The rest is performed according to the rules above laid down.
If, in spite of its apparent simplicity, this method has not been followed, it is
OPERATIVE SURGERY. 311
because, in reality, it is more painful and difficult than several others. It will
always be more rational to open the lachrymal sac with a bistoury than with
a trocar ; after that, Pamard's method is preferable to that of Jurine.
i. M. Fournier^s Method. — An extremely ingenious modification, and one
which I. am astonished not to have seen in our modern treatises, is that pointed
out by M. Fournier, of Lempde. This physician recommends to attach a shot
or a grain of lead to the ligature of Mejean. By its own weight, this will
pass through the canula of Desault, and tall into the interior of the nose, from
which the patient may make it pass without difficulty, by taking the simple
precaution of leaning forwards.
10. The editors of Sabatier have, it appears tome, justly observed, that the
combination of Mejean's and Petit's method may do away with all the instru-
ments of Desault, Pamard, Boyer, and Roux. What need is there, in fact, of
passing into the nasal canal successively, a probe, a stylet, a canula, and a
watch spring? Why not be satisfied with putting the thread in the conductor,
and passing the latter into the nose as so(m as the sac is opened ? The spring,
crotchet, and canula of M. Benezech, proposed in 1807, for the more easy
extraction of Mejean's stylet, have no superiority over most of the means
already spoken of, and consequently need no further mention.
j. Process of M. Jourdan, — Fearing lie should not otherwise expose the
whole extent of the disease, and wishing to avoid a cicatrix of the integu-
ments, M . Jourdan proposed to open the lachrymal sac behind the internal
commissure of the eye-lids, on the inside of the caruncle. M. Vesigne is
wrong, certainly, when he says that most frequently it will be impossible to
follow this advice ; but it is not the less true, that M. Jourdan's method offers
no advantages over the others; that it incurs the risk of wounding the inner
extremity of the lachrymal conduits, of dividing Horner's muscle, and will
produce more pain and present more difficulties than any of those now in use.
k. Process of Scarpa.^— Whiles in France, we were endeavoring to spread
the method of Mejean, the surgeons of Germany, Italy, and England con-
fined themselves to modifying that of J. L. Petit. After clearing the sac
and can'al by means of a tent covered with red precipitate, or of the nitrate
of silver, Scarpa advises us to pass a probe or conical nail of lead, terminated
by a flat head, more or less inclined upon the shaft, so as to accommodate
itself to the inner angle of the eye. This nail was to be withdrawn from
time to time, washed, and returned. During the first few weeks the surgeon
was to take care of this himself, and inject warm water into the lachry-
mal appendage before replacing the probe, which Scarpa called the con-
ductor of the tears. Afterwards the patient needed no assistance in per-
forming this dressing. When the tears begin to find their way without obstacle,
into the nose, and when the nail ceases to exhibit purulent matter on being
withdrawn, it may be laid aside ; yet it is best to continue it some weeks
longer, for greater security against a relapse. To some patients, says Scarpa,
it produces so little uneasiness, that they would be willing to continue its
use all their lives, and who have no repugnance to wearing it for eight or ten
months, or a whole year. I have seen M. Dubois and M. Bougon, in Paris,
use a cone of lead with success, which differed from that of Scarpa only in
having its superior extremity bent into a crotchet, instead of being flat, like
the head of a nail.
S12 NEW ELEMENTS OF
/. Process of Wore. — There are some who prefer a silver style to the
leaden tent which I have just mentioned. Dr. Ware, for example, introduced
among the English surgeons a silver nail or style, almost exactly similar to
tlie leaden one of Scarpa, and which M. Larrey has, in his turn, replaced by
one of cat-gut.
Permanent Canula,
According to Louis, Foubert conceived the idea of retaining a silver canula
in the nasal canal. It was about an inch long, conical, and terminated in some-
thing like the bowl of a spoon above. Bell and Richter had also spoken of this
canula, but Louis having formally denounced it, it was hardly thought worthy
of trial among surgeons of that time, notwithstanding the efforts of Pellier,
who, in 1783, announced himself as its inventor, and gave arguments in
his work which plead strongly in its favor. Pellier had also modified it
very ingeniously. His canula was shorter than that of Foubert, and ter-
minated in a smooth fillet above and a pen-point below, and had another
fillet round the middle, so that, once in place, it was impossible for it to go up
or down. It appears never to have fallen into complete disuse. M. Distel
published, that one of his patients wore one for more than fifteen years,
and that another of tin had been in use more than forty years. I see, too,
in a thesis published in 1803, that at the hospital of Strasburg no other
method is followed. M. Marschal has given us new and conclusive obser-
vations upon it. In Germany it was also employed by Himly and Reisinger.
But in the schools of Paris it had been entirely forgotten, when Dupuytren
recalled it to the recollection of our operators. He gave it but one fillet
instead of two. This fillet is concave within, where it presents a circular
gi^oove, and is so made that, to withdraw the canula, if any accident should
require it, it is sufficient to introduce into its interior the point of an elastic
forceps, terminated with two little crooks, with the points turned outwards,
to draw it upwards. That of M. Brachet, of Lyons, presents a second
swelling at its inferior extremity. M. Taddei; who speaks highly of it in a
memoir published in Italy, approaches much nearer than any others to the
views of Pellier, in advising a slight enlargement below its superior third.
M. Grenier, who thinks that the canula escapes only because it ceases to be
sufficiently pressed by the canal, has proposed one that will contract when
compressed, and enlarge again, like a spring, when left to itself.
To place it, it is necessary to have a stylet of steel, silver, or gold — which
is a sort of lever bent almost at a right angle — the inferior limb of which is to be
fitted to the calibre of the canula, and limited by a shoulder. The handle of the
instrument (the other limb) is more or less flat, and two or three inches long.
The lachrymal sac is to be opened as in the other methods. The stylet,
furnished with a canula of suitable dimensions, is then carried upon the back
or anterior face of the bistoury, so as to penetrate the nasal canal as that
instrument is withdrawn. When the enlargement of the canula has been
passed within the lips of the incision, it is to be fixed at this point by the nail
of the first finger, whilst the style is withdrawn. The patient is then required
to force out his breath, and if any of it pass by the angle of the eye, the opera-
tion is well done. M. Taddei thought that, before introducing the canula, it
OPERATIVE SURGERY. SIS
would be proper to remove the obstructions in the canal by a probe, or cylin-
drical stylet, and M. Cloquet does not introduce it until after using tents
for some days* It is said that M. Lisfranc makes a larger incision in
the integuments than M. Dupuytren recommends. But the stylet performs
exactly the office of a probe, doing thereby at once what M. Taddei effects
by two different operations ; and it is evidently useless to divide the parts
to a greater extent than is absolutely necessary for the passage of the canula.
To penetrate through the inner face of the lid, as recommend-ed by M.Yesigne,
to prevent a cicatrix, is certainly superfluous, and this is as^iuredly not a case
for conforming to the precept of Pouteau. For the purpose of rendering the
operation still more simple and speedy, Daviel invented a sort of trocar or
stylet, ending like a lancet point. This, by carrying the canula with it into
the canal, reduced the operation to a single process. This ingenious modi-
fication, although applicable to the more simple cases, would be often inconve-
nient, on account of the small opening it makes in the skin.
The canula should be of silver, gold, or platina, and of such strength as not
to be easily altered in its form. Its size and length should vary to suit the
subject. It is necessary it should exactly fit the calibre of the nasal canal, and
pass a little beyond its inferior extremity. Consequently, in an adult, it should
be from five to eight lines long, and from one to two lines thick. It should
also be slightly curved backwards and inwards, and its point, cut into tlie.
form of the nib of a pen, should prolong the anterior and external, rather than
tlie nasal side of the canal. To adapt it to the size of different individuals and
to their diffei-ent ages, M. Grenier has found a means which, it appears to me,
exactly answers the purpose. It is, that the length of the canal is represented
by a line drawn from the point of incision in the angle of the eye to the superior
depression in the ala nasi, at the junction of the inferior edge of the os malae
with the ascending apophysis of the maxillary bone.
Many objections have been made to this method. Here is a foreign body,
it has been said, which must necessarily fatigue the part, produce cephalalgia,
more or less uneasiness in the nose and face, erysipelatous affections, phlegmon
abscess, or ulceration of the angle of the eye. It often rises up under the
integuments, and requires to be withdrawn. M. Darcet has stated twenty-
seven cases where its extraction became indispensable. M. Delpech has seen
it pass through the arch of the palate. Mucosities and the snuffs which many
persons use, may obstruct or close the orifice, and thereby renew the disease,
as has been shown by M. Maunoir. Finally, when it requires extraction, we
must have recourse to an operation niore important than for the fistula lachry-
malis itself.
All these objections have some foundation. But, on the one hand, it is in
most cases the operator, and not the operation, that should be blamed for any
ill consequences that may occur ; and, on the other hand, there is no method
without risks of this kind. No doubt, if the canula slip in between the soft
parts and the maxillary bone, as I have twice seen, instead of remaining in the
canal it will give rise to more or less important symptoms, without being of
any benefit, properly speaking, to the fistula ; that this will also be the case, if
it be pushed into the maxillary sinus, or into the parieties of the canal ; if it
descend between the bone and the membrane of the canal ; in a word, if it be
not exactly in the natural route of the tears. It is also clear that a large canula
40
514
cannot be passed without danger through a canal too small, and yet, that if the
former be too small, the operation will be equally unsuccessful. But it is
the duty of the surgeon to know how to avoid these mistakes, or at least, when
he makes them, not to charge their eifects upon the method of operating. In
all other modes of operating, it is necessary to renew the dressings each day
for several months. There is none of them but what has been attended by
cephalalgia, erysipelas, &c. By Dupuytren's method, a few seconds only are
necessary to complete the operation. The disease is almost immediately
cured. No dressing nor particular care is indispensable. Most patients return
immediately to their habitual occupations. By this process we can secure
success in twelve out of twenty operations. A young woman whose lachrymal
duct was so small that I was compelled to use considerable force in introducing
a canula of a very small diameter, had a slight cephalalgia for three days. In
another case, that of a young man aged twenty-one, I had, as it were, to
force the duct in order to pass the canula. I kept him at La Pitie ; the next
day he was well, and no accident followed. The v/orst that can happen, after
all, is that we may be obliged to withdraw the instrument ; but this is not so very
serious or important ; it is done simply by finding again the superior opening
of the canal, and withdrawing the oftending body. When any difficulties are met
with, the double crotchet and canula of Dupuytren, the little hook of Cloquet,
or the two-headed mandrin of M. Caignou, will at once obviate them. We
might also use a pair of small dissecting forceps, one of the points a little turned
inwards. With any one of these instruments, by placing the hook in the
circular groove of the expansion, or beyond the extremity of the canula within,
we can draw it out quite easily, by making it follow the same route by which
it was introduced. I have withdrawn it four times, and found the dissecting for-
ceps always sufficient. It should b^ observed besides, that after the extrac-
tion of the canula, the patient is in just the same state as those who have been
treated the same length of time by the dilating method of Petit, and that many
find themselves even then radically cured, as I have twice seen. I would not
say that the canula is suited to all cases. When the canal has been thrown out
of its natural direction by exostosis ; when it is much closed by some hard sub-
stance or by ulcers ; or when it is the seat of more profound lesions still, it will
be better to have recourse to Mejean's seton, or some other more appropriate
method. I would only say that it is practicable whenever the method of Petit,
modified by Ware, Scarpa, or Dubois, can be applied, or any mode of treat-
ment depending upon mechanical dilatation, and that it is far preferable to
them all.
4. Cautery.
Fistula lachrymalis was treated by injections and tents introduced into the
nasal canal ; by escharotics, and even the actual cautery, before the course of
the tears was perfectly known. These various methods are clearly indicated
in the works of the Greek and Arabian physicians, and the authors of the
middle ages ; but it was under the same title with all other fistulous ul-
cerations. Their ignorance of the anatomy of the lachrymal apparatus did
not permit them to look upon it in any other point of view. For more than
a century cautery had scarcely been thought of, when, in 1832, M. Har-
veng, of Manheim, proposed to found upon it a new method of treatment. It
OPERATIVE SURGERY. 315
was soon seen that this duct resembled the urethra, and that its coarctations
might be submitted to the same general treatment. At present there are
two methods of applying the cautery : one by penetrating from above down-
wards, the other by introducing it through the nasal fossa.
a. Superior Operation. — 1. Process of M. Harveng. — After opening the
lachrymal sac, M. Harveng advises to pass a cautery at a white heat, or a tent
covered with nitrate of silver, through a canula to the obstructing points ; to
reapply it once, or oftener if necessary, and to proceed generally, as recom-
mended by Ducamp, in treating affections of the urethra. According to M.
Vail, who published a thesis upon it in 1824, Mortier, of Lyons, had a long
time before suggested the same idea, which was also attributed to M. Janson,
and that M. Taillefer, who has also been thought to be its author, again brought
it forward, in 1827.
2. Process of M. Deslande. — In the month of May, 1825, M. Deslande made
known another mode of accomplishing the same purpose. An ordinary
mandrin is at first introduced into the nasal passage, to remove obstruc-
tions and open the way for the port-caustique ; there is then slipt into its
place another instrument of the same form, with two longitudinal grooves in
its vertical limb, filled with fused nitrate of silver. The instrument is turned
upon its axis, so that the whole canal may be cauterized, and the operation is
finished.
b. Inferior Operation, — I learn from M. Blanc that, in 1824, M. Gensoul
dispensed with opening the great angle of the eye, and passed the nitrate of
silver by the inferior meatus of the nasal fossae. M. Bermond, of Bordeaux,
in 1825, inserted a memoir into the journals on the same subject. M. Valet
said something of it in a thesis, in 1826. And M. Ratien, who was no doubt
ignorant of these various attempts, announced, in 1828, that he hoped to be
able to apply Ducamp's method to the treatment of fistula lachrymalis, by
penetrating through the inferior orifice of the nasal canal. These surgeons
first propose to determine the place, the forift, and the extent of the disease,
and then to pass the caustic with certainty and facility. In penetrating by
the angle of the eye, as recommended by Mortier, Harveng, and Taillefer, the
operation presents no difficulty ; but by the other method, we must begin by
making ourselves familiar with the method of Laforest.
1. Process of M. Bermond. — After having introduced from without the
conducting thread of Mejean, M. Bermond attaches it to the ring of a tent
covered with wax, which he then draws into the nasal canal to take an impres-
sion of its form. By means of a thread attached to the free extremity of this
little bougie, he withdraws it by the nose, and puts in its place a tent made
of charpie, covered with a thick paste, which is rendered caustic in the parts
corresponding to the obstructions. This metliod, which is certainly the most
ingenious, has but one objection : it requires the previous introduction of a
thread through the punctum lachrymale, the canal, and the sac.
2. Process of M. Gensoul. — A small catheter, curved so as exactly to suit
the passage it has to traverse, is at first passed under the inferior corner and
into the nasal canal, to discover the seat of the disease ; which is then imme-
diately attacked with nitrate of silver, by means of a port-caustique. More
than three hundred cases have been treated in this way by M. Gensoul, some
with complete, others with partial success, and many without any advantage
516
NEW ELEMENTS OF
at all. In order to give his mandrin and canula a suitable form, he obtains
an exact cast hj means of the fusible alloy of Darcet. Some instrument*
made in this waj were shown me, in 1826, by M. Blanc, and I was truly
astonished at the facility with which they could be passed into the lachrymal
conduits.
Remarks.' — In proposing to cauterize the nasal canal, the surgeons I have
named have pretended to nothing more than to apply Ducamp's method to the
lachrymal passages'. If cauterization be proper for the obstructions of
the urethra, it must be equally applicable to those of the nasal canal, it is true;
but it appears to me, that in neither has the action of the remedy, nor the
affection which we seek to destroy, been accurately known. As in those of the
urethra, the contractions of the nasal canal are produced, and commonly con-
tinued, by a more or less extensive, more or less exactly circumscribed, chronic
phlegmasia. The spasmodic stricture spoken of by Janise, and to which Rich-
ter attributes so much, is never the cause of fistula lachrymalis. The affec-
tion of the lids, called in by Scarpa, only becomes a cause by spreading itself
to the lachrymal sac and as far as the nose, where, by the engorgement and
swelling it induces in the mucous membrane, it creates an obstruction of the
course of the tears. In other words, the fistula and lachrymal tumor depend
upon an induration, thickening, or simple chronic phlegmasia of some point
in the lachrymal passage. Now, in applying the nitrate of silver to an organ
thus altered, we do not cure it by producing merely an eschar or a burn, but
by dissipating the inflammation, by neutralizing or destroying the stimulus,
and producing thereby a resolution of the morbid engorgement.
It follows from this, that the nitrate of silver is the only caustic that can be
reasonably employed, and thp.t those casts or impressions of the canal with
which physicians have been so much occupied, are nearly useless. The prin-
cipal object is to make the caustic reach the superior part of the canal, if it
be introduced from below, and the bottom, if introduced at the other extremity,
so as to act upon nearly the whole extent of the passage. Whatever precau-
tions the surgeon may take to prevent this general action, will not avail. As
soon as the nitrate comes in contact with the living and moist membrane, it
melts and spreads itself in such a manner, that it is enough to touch one point
of the canal to make the whole feel its effect. And much the same may be
said of dilatation. When a tent or bougie, or the like is placed temporarily
or permanently in the nasal canal, it appears to me that it can only be useful
in one of two ways: by serving as a vehicle for medicinal agents proper to
dissipate the disease, or else by the compression of the affected canal, which
is cured in the latter case, not by mere dilatation, but by a true resolutive
pressure, the same as that which cures oedema, some kinds of dartre erysi-
pelas, &c,
5. Formation of a New Canal,
We see in Aetius and Paulus iEgineta, that Archigenes pierced the os
unguis with a drill, to give the tears a passage into the nose. Rhazes and
Avicenna cite Sabor-Ebn-Saiel, as an eulogist of this method, but which is
condemned by Mesne and Guy de Chauliac. Every thing favors the belief
that Celsus, Abul-Kasem,and Roger, of Parma, accomplished the same pur-
OPERATIVE SURGERY. SI?
pose bj the applicatiou of the actual cautery to the os unguis. But at least
G.de Salicet advises us, when the bone is diseased, always to cauterize it suf-
ficiently to allow tlie tears to pass into the nose ; which was also the method of
J. de Vigo. This operation was almost entirely forgotten for several centu-
ries, and owes its reintroduction into practice to Woolhouse. It was almost
the only manner of treating fistula up to the time of Petit and Mejean.
1. Process of Woolhouse. — The operator makes a semilunar incision at tho
greater angle of the eye, which comprehends the tendon of the orbicularis
palpebrarum ; opens freely tlie lachrymal sac ; denudes the os unguis, and
then fills the wound immediately with lint ; postponing the remainder of the
operation for twenty-four hours, or even two or three days, in order to be free
from the embarrassment produced by the blood. Then apointed wire is thrust
downwards, inwards, and a little backwards, through the inferior part, or the
larchrymal groove of the os unguis, into the nasal fossa. A tent, or a small
conical canula is afterwards introduced into the opening, to prevent its closing.
Then, when the edges have cicatrized and become callous, a canula of gold,
slightly contracted in the middle to prevent removal, is introduced and per-
manently retained.
2. Process of Saint Yves. — Saint Yves, who had noticed, as all other opera-
tors had, that Woolhouse's method was almost always followed by inflamma-
tion, or by an eversion of the eyelids, perceived that this inconvenience could
be avoided by avoiding the tendon of the orbicularis muscle in the incision
at the angle of the eye. He also prefeiTed perforating the os unguis with the
actual cautery, so as to occasion an actual loss of substance.
3. Dionis^ Process. — Lacharriere, Diorys, and Wiseman, also recommend
the cautery, which they passed through the lachrymal sac, protected by a
funnel-shaped canula.
4. Process of Monro. — Schobinger, Monro, and Boudou, used a trocar to
perforate the bone, fearing less than Woolhouse to wound the ethmoides.
Ravaton thought to accomplish the same purpose by means of a quill, a curved
forceps, with which he l)roke away the os unguis to a considerable extent, and
a leaden canula; but none of these methods will be followed by a perfect
cure. Although the artificial opening may be maintained by a tent or canula
for some time, it almost always closes up at last ; and it is rare that the
canula of Woolhouse can be retained long enough to render the new passage
permanent.
5. Htmter^s Method. — Hunter thought he should succeed better by taking
away at the same time a disc of the os unguis and of the two membranes that
covered it, so as to form a circular opening two lines in diameter, attended
with a complete loss of substance. To accomplish this, he invented two
instruments ; one, a kind of canula with a cutting extremity, like a harness-
^ maker-s punch ; die other, a flat piece of horn or ebony, curved so as to be
passed into the nasal fossa to serve as a support on which the punch was to
act. With these a very neat opening could be made in the greater angle of
the eye, which it would be enough to dress with a plug of lint to cause it to
cicatrize and become rounded and callous. As it is almost impossible to apply
the nasal plate, and as the perforation witli the actual cautery is also accom-
panied with loss of substance, without being. followed with success, n6 per-
318 NEW ELEMENTS OF
son has yet attempted the operation of Hunter upon the living subject, and
he appears never to have tried it himself, except upon the dead subject. But
if any one should wish to try it again, he can very easily do it with the punch-
ing compasses of M. Talrich, or those of Sir Henry. The pierced branch,
introduced into the nose, serves as a point of support to the perforating branch,
which is applied to the greater angle directly through tlie wound in the canal.
Then, by pressing them together, a portion is removed without any risk of
injury.
6. Scarpa's Process, — Scarpa and M. Bouchet have lately returned to the
use of the actual cautery, according to the views of Saint Yves. That is,
after opening the greater angle, as in the operation for simple fistula, without
touching the tendon, they fill the wounds with charpie, and leave it so for
twenty -four hours or more. Then, with a metallic wire heated to whiteness,
they penetrate from the inferior and internal part of the lachrymal sac into
the nose. To secure the eye and neighboring soft parts from the action of the
cautery, Scarpa used not the simple funnel of Verduc or Dionis, but a conical
canula, with the sides very thick, and furnished with a handle several inches
long, connected with the base at a right angle, invented by Manoury and used
by Desault, and of which the first ideas are found in Roger, of Parma.
Rivard and A. Petit open the sac behind the lid, like Pouteau, whether de-
siring to penetrate into the nose or to stop at the canal. •
7. Process of M. Nicod. — More recently, M. Nicod has proposed to com-
bine perforation with the trocar and the actual cautery.
8. Process of M. Pecot. — Supposing that he had observed that M. Briot, by
mistake, once introduced the canula through the os unguis, and once in the
antrum highmorianum, without any bad consequences, M. Pecot, of Besancon,
thought it would be well to fix the canula in the maxillary sinus through the
external and posterior wall of the canal, instead of searching with painful
obstinacy for the canal itself. This is better than nothing, doubtless, if nothing
else could be done ; but I doubt, notwithstanding the reasons recently adduced
in its favor by M. Laugier, whether such a method will ever obtain many
advocates. There is no proof that when the tears have reached the sirfus
they can escape easily from thence, and that they may not produce serious
symptoms there. The perforation of the os unguis lias fewer inconveniences.
Remarks. — Woolhouse's method, rejected by Marchetti, Solingen, Maitre-
Jean, and especially by Nannoni, will be but rarely adopted at the present
time. Wherever it is possible to operate upon the natural passage, it would
be wrong to attempt the formation of a new one. Where it is not, it is more
rational to imitate M. Dupuytren in making a new passage in the direction of
the natural one, than to perforate the os unguis or the sinus, like Saint Yves
or M. Pecot. When there is necrosis, the fistula sliould be treated by one of
the other methods ; for the disease of the bone requires no other care than if
it had had its seat in any other part of the body. The employment of the
actual cautery, or of chemical escharotics, is always dangerous so near the eye.
They have more than once produced obliteration of the lachrymal conduits,
and consequently incurable epiphora. The value of Woolhouse's method is
still further lessened, by the fact that the tears rarely acquire the habit of
falling into the nose even when the route which has been opened for them
OPERATIVE SURGERY. 319
continues open ; so that, besides the deformity at the gi'eater angle of the eye,
the patient remains affected with a weeping most frequently beyond the reach
of art.
Whatever method may be preferred, there is one step nearly the same in all ;
I mean the opening of the sac and the exploration of the canal.
In order to have every possible assurance of reaching the canal, the ope-
rator is to be aided by an assistant, who draws the eyelids towards the temple ;
with the index linger corresponding to the diseased side he seeks in the
greater angle for the anterior lip of tlie lachrymal trough, and disperses by
gentle pressure any gummy matters that may lie there. Then, seizing a
sti'aight, firm, and narrow bistoury with the other hand, he passes the point
of it behind the nail of the directing finger, and sinks it obliquely inwards,
backwards, and downwards, into the sac. Then, raising the handle of the
instrument towards the eyebrows in order to descend perpendicularly into
the nasal canal, he calls for a drill armed with a canula, if he intends to
follow Foubert's method, or a grooved sound or stylet, if he wiahes to imitate
Petit or Desault, and carries its extremity upon the back or the anterior face
of the bistoury in such a manner that, while the latter is being withdrawn, it
serves as a director for the former. When the opening of the fistula is suf-
ficiently large to permit the passage of the canula or the sound, the bistoury
may be dispensed with. In other cases the ulcer may be left above, below, or
at the side of the incision, acting, in fact, as if it did not exist ; if it be sur-
rounded with troublesome fungi, they are first removed.
When he does not follow the process of M. Bermond for cauterizing the
canal upwards, the operator, holding the catheter or probe as a pen, introduces
it, with the concavity turned downwards and outwards, to the depth of about
an inch; then, raising the outer end a little, that the other may become
engaged under the inferior spongy bone and glide upon the nasal wall, with •
draws it gently to within six or eight lines of the opening of the nose ; turns its
concavity by degrees outwards and upwards ; then, by a cautious swaying
movement, endeavors to introduce the beak of the instrument into the orifice of
the nasal canal, whence the instrument may be passed without difficulty to the
angle of the eye, or into the lachrymal sac. Force here is never necessary.
Resistance can only arise from a bad direction of the instrument, or some
anatomical variation. By inclining the sound too much upwards or down-
wards, inwards or outwards, its summit may be carried against the opposite
wall, or the circumference of the inferior orifice of the canal. The curva-
ture of the sounds of Laforest is bad, making the operation difficult and
hazardous. These instruments should not form the arc of a circle, but be
bent at almost a right angle, and be very blunt. With this form, the passage
of the canal is really very simple, and I think, with Versigne and Gensoul,
that modern operators are wrong so entirely to neglect it.
The lachrymal conduits and puncta may be obliterated by a variety of dis-
eases, such as erysipelas, small pox, &c., producing a continual weeping, as
stated by Anel, J. L. Petit, &c. Yet Gunz says that he saw a case of tliis
kind, where the tears had found a passage into the canal by means of poro-
sities visible to the naked eye.
Mejean's stylet, passed from the sac towards the lids when the obstacle is
near the orifice, or towards the nose when it has its seat lower down, will, in
S20 NEW ELEMENTS OF
some cases re-establish the passage for the {cars ; otherwise the di^^^ease is
almost incurable. Jt will be useless to attempt the formation of a new duct
* with a needle, drawing after it a thread or seton. The tears will not pass by
it. It cannot be kept open, nor made to suck or absorb the lachrymal secre-
tion like the natural one. Nor is there better reason to believe that epiphora
would be prevented, by making, like A. Petit, an opening into the sac
beliind the internal angle of the eyelids, because the artificial orifice never
acquires the organization of the punctum lachrymale. Nevertheless, it is
almost the only resource left us in such a case.
If an ulcer, or other lesion, perforate the lachrymal conduit towards the
eye, there results a fistula of a peculiar kind very difficult of cure. A thread
of gold or silk, or better, of small cat -gut, passed like a seton through the
v/ounded conduit from the punctum to the sac, is the only remedy we have
for such an infirmity, unless we lay open the canal from the inside of the lid.
Instead of opening at the greater angle of the eye, the lachrymal tumor
sometimes makes its way into the nose through the os unguis, of which Heister
gives an example. In internal fistulas, it is not the re-establishment of
the natural course for the tears that requires our assistance, but the cure of
the ulcer. If there be a tumor, even if the conduits or puncta are closed,
we have no other treatment to apply than that which is necessary for an abscess,
or for chronic inflammation. First, compression, resolvents, or astringents;
then an opening of the cyst with the bistoury, and the subsequent employment
of a tent or detersive injections, are all that is necessary, unless we place a
permanent canula in the canal.
However much the sac may be distended, it is rare that we shall have oc-
casion to follow Mr. Boyer's precept, to excise a portion with the scissors, or
that of M. Guerin, to resort to compression. Cauterization with the nitrate
of silver, as recommended by Scarpa, is evidently preferable.
Jirt, 9,.— The Eyelids,
§ 1. Ectropion.
Eversion of the lids may be produced by two causes: swelling of the con-
junctiva and contraction of the skin. The latter, properly called ectropion, is
the most serious. The former, which is more easy to cure, and more rarely
seen, shows itself in an acute or a chronic form. It forms what is called lag-
ophthalmia. When recent, cauterization with a proner instrum.ent, as directed
by G. de Salicet, ordinarily produces a cure. M. J. Cloquet cured it in this
way, when of more than a year's standing. Saint Yves and Scarpa praised
the nitrate of silver in such cases ; and a great many dry collyria have been
u§ed with like success. Calomel and sugar, tutty, white oxide of bismuth,
finely pulverized, with an equal part of sugar-candy, have obtained me sur-
prising and prompt success, applied by pinches night and morning upon the
engorged part.
When these have been tried in vain, we may imitate Acrel, in passing a
thread-through the lid near its ciliary border, with which to draw the lid into
its natural position ; or instead of the thread, we may use strips of adhc-
OrPERATIVE SURGERY. 321
sive plaster, as recommended by J. Frabricius and Solingen, the free ex-
trepiitj of which is to be fixed upon the forehead fcrr the lower lid, and on
the cheek for the upper. But it is much more simple, sure, and prompt to
excise the fungous conjunctiva at once. It is the method adopted by all the
moderns, and prescribed bjAntylus, and even recommended by Hippocrates,
although confusedly, where scarification has been unsuccessful. While
the lid is held everted by an assistant, the surgeon seizes with a dissecting
forceps, held in the left hand, a portion of the membrane large enough to
bring the cilia to their proper situation, but not so large as to invert them.
He then cuts this fold from the greater angle towards the smaller for the right,
and the contrary for the left eye: endeavoring not to comprehend in the
incision any thing more than the conjunctiva, and to keep nearer to the globe of
the eye than to the edge of the palpebra. For the operation straight or curved
scissors should be used. A sharp bistoury or a good lancet would serve, but
scissors are best. The blood, which flows abundantly at first, soon stops of
itself, and the operation, properly speaking, is done. The treatment of the
rest is the same as that for an ordinary or traumatic ophthalmia. The cica-
trization of the wound brings back the tarsus into its natural position. Paulus
Egineta used a thread passed transversely from one angle of the eye to the
other, to elevate the conjunctiva for the incision. The scars left upon the
skin of the face by burns, small-pox, wounds, or ulcers, often produce an
ectropion much more difficult to cure. Desiccatives and caustics applied
upon the palpebral conjunctiva aiFord no relief. It would be in vain to
replace the lids w^ith a thread or adhesive strips. The actual cautery, or the
excision of the relaxed membrane, is commonly useless. Many operators,
even among the moderns, agree in considering the disease incurable. Until
the time of Boerhaave and Louis, there were a variety of ways for lengthening
the external face of the lid thus everted. Since, with Demosthenes of Mar-
seilles, Celsus, and Pare, made a semilunar incision of the skin, having its
horns turned towards the opening of the eye; others contented themselves with
a transverse incision, the lips of which they endeavored to keep apart with
charpie or some other foreign substance ; others again, as Paul of Egina, and
Olof Acrel, carefully destroyed all the cicatrices of the skin, either by
incision, excision, or strangulation, by means of a ligature. But it is well
known, that so far from being advantageous these various methods are almost
always injurious, and in spite of every precaution, the resulting sore contracts
the teguments of the lid instead of favoring their elongation.
1. Process of Antylus. — In 1813, an English oculist, Mr. Adams, proposed a
method of operating for these difficult cases, of which he thought he was the
originator, but which Mr. Martin attributes to Dr. Physick, of Philadelphia, or
to M. Bouchet, of Lyons, and which is found long ago described by Aetius,
who refers it to Antylus. A triangular piece of the affected lid, of the form of
a V, is to be removed, the base corresponding to the cilia ; the sides of the
opening left are then united by means of a suture. Mr. Adams's method has been
followed in France, by Beclard, and more especially by Roux. I have seen
it used, and used it myself several times with success. Antylus, who made
his incisions from the adherent towards the free edge of the lid, took care to
divide nothing but the conjunctiva, the tarsus, and the orbicularis muscle; in
a word, leaving the skin untouched. Mr. Adams and M. Roux first seize
41
322 NEW ELEMENTS OF
the lid with a ligature forceps, and then cut on each side of it through the
whole thickness ; thus forming the triangle bj cutting from its base to its
Jipex. The blood, though flowing abundantly at first, because the ciliary or
palpebral artery is necessarily divided, soon stops. Mr. Adams is contented
with a simple stitch near the cilia to secure reunion. Mr. Roux treats it
exactly like the hare-lip; that is, he applies the twisted suture with two short
strong pins. Instead of a bistoury, I tliink it would be better to use a pair of
good scissors, as I have twice done. With them the operation is more prompt
and sure, and the section of the tissues more neat and easy. I see no neces-
sity for making the base of the flap more tlian two or three lines long, and
prolonging it beyond the cartilage.
2. Process of M. Walther. — In a case in which the ectropion occupied only
the temporal half of the eye, Walther, after having plucked out the eye-lashes,
seized the external extremity of the inferior lid with a pair of forceps, and
then incised it through its whole thickness to the temple ; he did the same with
the superior lid, and removed the flap contained within these limits. The
lips of the wound being drawn together, were kept in place by two stitches,
and the patient perfectly cured. Tliis method is evidently none other than
that of Antylus and Mr. Adams, applied to the smaller angle of the eye, and
would be applicable only in such cases as the one that came under the care of
M. Walther.
3. Process of Dr. Key. — In 1826, Doctor Key had to treat a case of ectro-
pion, which Messrs. Travers, Tyrrel, and Green had in vain attempted to cure
by the usual method. Imagining that the eversion of the lid in this case
might depend upon the spasmodic contraction of the orbicularis muscle. Dr.
Key made a transverse incision through the skin, dissected carefully to the
convex edge of the tarsal cartilage, directed an assistant to separate the lips
of the incision, and then with a forceps seized a fasiculus of muscular fibres,
whicli he divided with a pair of fine scissors. The operation was completely
successful. I do not know whether operators can fully adopt Dr. Key's views,
nor if I have given them exactly ; but this is certain, we cannot comprehend
the existence of these pretended spasmodic contractions, nor how the excision
of a part of the orbicularis muscle can remedy ectropion. Yet, in surgery
at least, when a fact is advanced, whether it be comprehended or not, pru-
dence requires us to admit it. I have therefore felt myself bound not to pass
over in silence the operation of the English surgeon.
4. Blepharoplastic Operation^ — This is anoperation very recently proposed,
and which two operators have already tried. Founded upon the principles of
the Indian rhinoplastic operation, tliis method consists in excising tlie cicatrices
which cause the ectropion, and in the formation of a flap taken from the cheek
for the lower lid, and from the forehead for the upper ; fixing it in the place of
the excised tissues by means of a suture, and taking care to divide its root
about the fifth or eighth day. By this means M. Frick was completely suc-
cessful on a subject sixty-three years old ; but M. Juncken failed completely
in the two attempts which he made.
If the ectropion be caused by a tumor of any kind in the interior of the
orbit or in the lid, it is scarcely necessary to say that the surgeon should
occupy himself with the tumor, and not with the everted lid.
OPERATIVE SURGERY. 323
§ 2. Trichiasis, Entropion^ and Blepharoptosis.
When the superior eyelid becomes so far permanently depressed as to close
the eye completely, and the cilia are not inverted ; whether it depends upon
a relaxation of the elevator muscle or any other cause ; if it be of long standing,
and has resisted the use of antiphlogistics, stimulants, and other therapeutic
agents, either local or general, we are then called upon to oppose surgical
means to this blepharoptosis.
1. Excision. — The operation, which is nearly the same as for ectropion and
trichiasis, has been considerably varied. Hippocrates passed two loops of
thread through the skin, so that one end came out near the free edge the other
near the base of the lid, and tied these extremities together so as to evert the
cilia ; but the method by incision of a transverse cutaneous flap, has attracted
more particular attention. This incision has been carefully described by
Celsus and G. de Salicet, and is variously performed. Acrel, who proposed
it in his turn, recommended the removal of a lozenge-formed flap. As this
did not appear to him always successful, he had the boldness to incise the
integuments above the brows, thus removing a considerable segment. Celsus
and Galen traced the limits of the portion they wished to remove with ink,
and brought them together by a single stitch. Aetius recommends the upper
incision to be semilunar, and the lower straight. Instead of one stitch, he
employed five. Paul of Egina commenced by a transverse incision of ikt
internal face of the lid, extending from one angle of the eye to the other.
Rhazes used caustics, Abul-Kasem used a hot iron or quick-lime, and
gave his wound the form of a myrtle leaf. Costeus and Scachi extolled
the actual cautery. Recently M. Heling and M. Quadri have spoken highly
of sulphuric acid. The Neapolitan professor begins by moderately separating
the lids, which he washes, wipes, and dries carefully with fine linen or a
sponge. Then, with the aid of a small piece of polished wood, he places the
acid upon that part of the skin that corresponds to the lowest portion of the
tarsal cartilage, spreading it from four to six lines transversely ; waiting some
seconds for the first application of the acid to combine with the tissues, he
reapplies it a second, third, and even fourth time, or until the lid is slightly
shrunk outwardly ; taking proper precaution in the mean time that the caustic
may not penetrate into the eye.
ITie excision of the skin and cauterization with sulphuric acid, produce
evidently the same ultimate results. By both methods there is a loss of sub-
stance. It is necessary that the lips of the wound s.hould approximate, to
produce cicatrization ; and by this means a contraction or shrinking of the
lid, and principally of its external face, is obtained. After making the inci-
sion, to which an extent may be given suited to the degree of retraction
desired, should we, like those who first employed it, as well as Beer and
Langenbeck, have recourse to the simple or quilled suture ; or, like Scarpa,
content ourselves with plain dressings, and wait for a reunion by the second
intention. This appears to me a matter rather of choice than of neces-
sity.
2. Extraction and Cauterization of the Cilia. — One of the most ancient
methods of curing trichiasis, and especially destichiasis, is the extraction of
the erratic haira. Popius, according to Galen, was its inventor. Nothing
324 NEW ELEMENTS OF
can appear more natural, as a remedy for the pain and inflammation which the
eje suffers in this disease, than a removal of the cause. Unhappily, we are
soon taught that this remedy is only palliative, curing it only for a while ;
and that the renewed cilia almost constantly take the former vicious direc-
tion. Still it is almost the only plan adopted by Vauguyon, Maitre-Jean, De
la Motte, and even Richter, when the tarsus itself is not diseased. To guard
against the recurrence of the malady, some operators apply caustic to the
roots of the hairs after extracting them. Sulphuric acid, butter of antimony,
and nitrate of silver, have been in turn extolled. Seeing that none of these
will suffice, some have used the actual cautery, according to the advice
of Rhazes. M. de Champesme, in our own times, has found nutliing better for
trichiasis than an improvement of the cauterization used by many of the
ancients. The form of the ancient cauterizin<>; instrument did not allow the
heat to be carried sufficiently deep. Hisis terminated by a point some lines
long, supported by a large ball, and resembles somewhat the cautery called
the sparrow's head. Heated to whiteness, the point, although small, long
retains heat enough to form escars promptly wherever applied. M. de Cham-
pesme affirms, that he has many times cured trichiasis radically with his
instrument, and no one can deny its advantages when cautery is decided
upon.
3. Eversion of the Cilia. — A means less cruel, and one v.l.Ich appears to
have been attended with some success, consists in everting or turning out
the strayed eye-lashes upon the skin of the lid. Heraclide, who passes for
its inventor, maintained them in that position, like Acton, by means of plasters,
I used this method in a case which resisted the excision of the integuments.
Celsus and Galen say, that in their time some persons operated by passing a
woman's hair, doubled, through the skin with a needle, in such a way as to
secure the erratic lashes in the curl of the hair. According to Rhazes, we
may succeed as well by crisping them with a hot iron.
Remarks, — The excision of the skin, so strongly recommended by Borde-
nave, Louis, Scarpa, and almost all of the moderns, is an operation too simple
and too frequently successful, not to be a first resort. The surgeon, placing
himself in front of the patient, seizes, with an ordinary forceps, the fingers,
or Beer's forceps, a fold of the integuments sufficiently large to return the
cilia to their proper place outwards and upwards. If the Ibid be too large,
he exposes himself to produce ectropion ; if too small, to an incomplete cure
of the trichiasis. It is to be excised in the same manner, and with the same
precautions, as the fold of the conjunctiva in lagophthalmia or simple ectro-
pion. After the operation, Scarpa recommends that the skin of the face for
the lower lid, and of the brows and forehead for the upper, should be forced
towards the orbit, and kept tliere by graduated compresses or adhesive strips
extending from the cheek high upon the forehead. The next day, he says,
the patient can open his eye ; and if any granulation or fungous growths show
themselves, they should be repressed by the lajm infemalls. M. Beer and
M. Langenbeck recommend the use of the suture, that the eye may be relieved
as soon as possible from the effects of the presence of the cilia. As the di-
vided skin is very thin and elastic, as nothing is easier tlian to take a stitch in
it, and as it is always better to unite it immediately without crowding in the
neighboring integuments, like Scarpa, I cannot see why there should be any
OPERATIVE SURGERY. S^5
repugnance to the use of a simple suture, were it but for twenty-four hours,
as recommended bj Langenbeck.
Avenzoar speaks of some operators who preferred compressing the flap of
the integuments between two splints, until it produced mortification. Bartisch
has reproduced this idea under another form ; he engages the fold between
two plates of iron united by a hinge. Adrianson, according to Heister,
invented a method still more strange: with an instrument very similar to that
of Bartisch's, garnished with holes, he pinched up a large fold of skin ; he then
passed threads through the base and the holes of the instrument, removed
the latter, and tied the threads as so many ligatures.
4. Excision of the Edge of the Palpebra. — In some obstinate cases, Dr.
Schreger removes, with curved scissors, a triangular flap of the edge of the
lid, comprehending the erratic hairs ; and even went so far, says Mr. S. Cooper,
as to advise the excision of all the inverted portion of the tarsus. But we
cannot see in what this method, also eulogized by Heister and D. Gendron, is
superior to a simple excision of the palpebral integuments.
a. Mr. Crampton's Method. — After dividing the free edge of the lid to the
right and left of the deviating hairs perpendicularly, Mr. Crampton united
these two incisions by a third transverse one of the conjunctiva ; then drew
the included portion of the cartilage to its natural position, and maintained it
there by adhesive strips, or other appropriate dressing. Mr. Travers, who
has partly adopted Mr. Crampton's views, thinks that in certain cases it would
be better to remove the little trapezoidal portion of the tarsus. The phy-
sicians of Bimarestan, of whom Rhazes speaks, and who incised the cartilage
and pierced it with a thread, with which they everted it ; Richter, who advises
us to make a transverse incision of the tarsus in obstinate entropion ; and Paul
of Egina, who advises to cut through the lid by the inner face, have given
birth, we see, to the idea on which Mr. Crampton's operation is founded. At
best, this is only a resource in extreme cases.
b. Mr. Guthrie^s Method. — Mi:. Guthrie also cut the tarsus, but near the
angles of the eye ; with the finger he then everted it towards the forehead, or
the cheek, according to the lid affected. If, on being allowed to fall on the
eye again, it continue inverted, Mr. Guthrie recommends to divide it trans-
versely, and to remove a portion of it, along with the skin that covers it.
Without being good enough to merit great confidence, this method seems less
objectionable than the preceding.
c. Saunder^s Method. — The surest way, says Dr. Saunders, is to remove
almost the whole of the diseased organ. A thin plate of lead, or silver,
curved to suit the lid, being first placed between it and the part, the eye being
stretched by an assistant, ^he operator divides the skin and orbicularis muscle,
a little beyond, and in the direction of the tarsus, behind the cilia. The inconve-
niences of such a plan are but too evident. It would be better to follow the
advice first given by M. Jaeger, of Vienna, and afterwards by M. Flarer, of
Pavia, to excise the cutaneous portion of the free edge of the lid, and with
it, the erratic hairs and their roots.
d. Method of Vacca-Berlinghieri. — The operation of Vacca seems to me
much more reasonable. In a most obstinate case of trichiasis, this surgeon
thought he could expose the roots of the hairs, and destroy them, either with a
cutting instrument or nitric acid. A thin concave plate, with a transverse
326 New tLEMEKfTs o?
groove upon its convex face, is placed upon the globe of the eje. An assist-
ant holds the lid with the free edge in the groove of the plate. J5j means of
two vertical incisions, one line long, united by a transverse one which com-
prehends the skin only, the operator forms a small parallelogram, which he
turns forwards towards the opening of the eyelids; by this means the cartilage
is exposed ; he then seeks the bulbs of the diseased liairs with the pincers ;
excises them with the scissors, or cauterizes them ; replaces the flap, and
maintains it in place with plasters. The ciliary branches of the palpebral artery
are cut, and bleed abundantly ; but the hemorrhage is unimportant, and stops
of itself. M. Delpech, who also eulogizes the cauterization of the cilia, not
of the bulb, but the neck, depends principally upon the formation of an elastic
cicatrix, a layer of imperforated tissue, and consequently preferred union by
suppuration.
Recapitulation. — In simple blepharoptosis, excision of the integuments is
almost always successful. It is also the most efficacious remedy in ordinary
entropion. In trichiasis, the turning out of the hairs, after the manner of
Heraclides, when their length permits, or of Hippocrates, can be first tried.
Then comes, 1st, the excision of the integuments, which Dr. Physick advises
to be made very near the free edge of the palpebra, and which I have just
seen fail in a very simple case; 2d, cauterization of the skin after the
manner of Helling and Quadri, which I have once used with success ; 3d,
Vacca's method for more serious cases ; 4th, and lastly, excision of the car-
tilage, according to the views of M. Guthrie, Schreger, Travers, Saunders,
Crampton; or even by the process of Mr. Adams.
§ 3. Tumors.
I. Cysts. — If any tumor, occupying either lid, does not disorganize but only
deform the lid, the tumor should be destroyed without removing the natural
organ. Encysted tumors come under this head. If the vinous solution of
the muriate of ammonia, recommended by Morgagni and M. Boyer, should
fail, and the patient desires to be relieved of the affection, it is time to think
of the operation, properly so called. Ligature, incision, cautery, and extirpa-
tion have been proposed. The ligature has been for a long time justly
abandoned. Simple cauterization has shared the same fate, at least when
not combined with incision. A needle fixed like a seton in the tumor, as
recominended by M. Jacquemin, would, I think, only succeed by chance. So
that it is only extirpation that is worthy of our attention.
To effect this, it is useless to pass a thread through the tumor, as Bartisch
advised, so as to act upon it more securely. Whei; it is small, and has its seat
apparently nearer the conjunctiva than the skin, Richter recommends that the
offending body be removed by the inner face of the lid, because it then leaves
no visible cicatrix after the cure. The great prominence which it presents
outwards should not mislead us, for this projection more frequently depends
upon the pressure of the globe of the eye than the seat of the tumor. The
cures are therefore very few — when the skin is altered and thinned, for in-
stance, or when it is too difficult to evert the lid, in which we are obliged to
divide the external integuments.
First Process. — With the thumb upon the inner face of the tarsus, and the
OPERATIVE SURGERY. 327
index fiho;er applied upon the skin, the surgeon takes hold of and everts the lid ;
then, pressing upon the tumor to give it prominence, he lajs it bare with a
transverse incision, seizes it with a hook which he confides to an assistant,
and then with a bistoury dissects it out. The small wound resulting requires
very little care ; cicatrization takes place in a few days. AVhen the tumor
is secured by the hook, if it be small and easily raised up, it may be removed
by a single cut with a pair of flat curved scissors. Yet it is important to pre-
serve the conjunctiva and subjacent tissues, because their destruction exposes
the patient to entropion.
Second Process. — When from necessity or choice we would remove the tumor
through the skin, the index finger takes the place of the thumb, and the thumb
the finger. By pressing the tumor, the finger stretches the lid, and protects
the eye much better than the cupola of lead or silver formerly used, or the
plate of lead, gold, or copper, still recommended by Chopart and Desault. ,
The integuments are then cautiously dissected, to prevent the opening of the
morbid body. The rest offers nothing particular. Short strips of taft'eta or
diachylon plaster maintain the lips of the wound in contact, and we have
rarely to wait more than three or four days for a cure.
Care should be taken in both these processes to avoid cutting through the
lid, or wounding if it can be avoided the tarsal cartilage ; because it may
retard the cure, and even produce a fistula, or some other deformity.
Modified Cauterization. — Maitre-Jean, Heuermann, and Nuck, commenced
by opening the tumor freely so as to empty it, and then applied the actual
cautery to its interior. Chopart and Desault, who professed the same
opinions, used a pencil of lapis infernalis. M. Dupuytren, in adopting this
plan, founds his preference upon its greater ease and security — preventing a
perforation of the lid; and upon its being the only one that can be used, when
in spite of all precautions the cyst has been opened in endeavoring merely
to expose it. The operation is very simple. The organ is held as in the
preceding methods. With one stroke of the bistoury we divide the skin and
the little sac, which empties itself, or should be emptied ; its whole inner
surface is then cauterized with a stick of nitrate of silver, pressed upon it
v/ith some force ; the heterogeneous crust soon comes away, and the wound
heals quite readily. All things equal, excision is to be preferred. But M.
Dupuytren's method is hardly less advantageous, and would be very appli-
cable upon refractory subjects. I have employed both with equal success.
Cancerous Tumors. — Experience has sufficiently proved that cauterization
is a bad means of destroying cancerous tubercles of the eyelids. If the
tumor be of a less alarming nature, still it is better to attack it with the cutting
instrument if the degeneration has extended to the natural tissues. Here, as
elsewhere, it would be better to do nothing than leave a portion of the disease
for fear of cutting into healthy parts. When there exists but one tubercle
well defined, occupying only the border of the tarsus, it is best to isolate it by
means of two incisions uniting in a V, thereby removing a triangular flap with
it ; using the twisted suture to bring together the edges of the wound. If the
alteration be more extended transversely than vertically, so that after extirpa-
tion we should think it impossible to bring together the edges of the incision,
we should then make a semilunar incision of greater or less length and depth,
either with a good bistoury, or, as M. Richerand prefers, with curved scissors ;
328 NEW ELEMENTS OF
taking all possible care not to injure the lachrymal puncta or conduits. The
solution of continuity cicatrizes by suppuration. The integuments slowly
increase upon the eye, and terminate by forming a kind of hood, which par-
tially replaces the lost lid.
§ 4. Anchyloblepharon and Symblepharon.
The adhesions that occur between the lids and globe of the eye have been
long observed. To destroy them Heraclides used a bistoury, recommend-
ing the edge of the instrument to be inclined rather towards the lid than
the globe ; and to prevent the reproduction of the disease, advises the patient
to move the eye frequently in every direction. When the adhesions are weak,
or small in extent, it is sometimes possible, as Alex directs, to destroy them
with a sound or stylet. If they assume the form of bridles or lamellag, beyond
which a grooved sound may be passed on the globe, they may be divided, ac-
cording to the advice of Maitre-Jean and M. Boyer upon this instrument, with-
out danger. No one now, as in the days of Bartisch, thinks of raising the lid
with a thread or ligature to dissect it from the ball. The most important
matter is, not to break these connexions, but to prevent their reproduction.
The constant motion recommended by Heraclides, the plates of lead, gold, or
copper, recommended by Solingen and others to be placed between the eye and
lid, but rarely accomplish this purpose. The best plan is to pass from time to
time a ring or a large pin-head between the contiguous surfaces, so as to cause
them io cicatrize separately. It is an operation after all which should only
be attempted upon those who have a healthy transparent cornea, or at least
those whose cornea is in that state in the part opposite the pupil.
Congenital or acquired adhesion of the edge of the lids, always less import-
ant, may be complete or incomplete, and may exist alone or in conjunction
with the preceding disease. In the first case, instead of opening with the bis-
toury the whole extent of the line which the natural state should present from
before inwards, we should make a small opening near the temple, in order
to introduce a grooved silver probe, a little concave on its back, that it
may accommodate itself to the convexity of the eye. The bistoury, guided
by this conductor, is passed without danger from one palpebral commissure to
the other in the track made by the junction of cilia. In the second case, the pre-
paratory incision is unnecessary. After separating the lids, if there exist anchy-
loblepharon, it should be destroyed according to the rules abovementioned .
Instead of the bistoury and sound, it is possible to use a pair of scissors, guarded
by a small ball of wax, as recommended by J. Fabrice, or a small button, as
advised by Scultet, at the end of that blade which is to pass next the ball of
the eye. But it would be trifling to pass a wire of brass behind the abnormal
connexion and bring together its two halves, like Duddell, in order to separate
the adhesions insensibly. Nor would any person expose himself to the ridi-
cule of imitating F. de Hilden, who tied the two extremities of this wire
together, and attached to it a weight to draw it out by degrees. As after every
method the disunited edges retain a great propensity to reunite, the surgeon
should not omit to place between them some pieces of charpie covered with
cerate, near the commissures, nor to separate them frequently with a wire or
ring of gold or silver.
OPERATIVE SURGERY. S29
Encanthis, — Scirrhous, or other degeneration of the caruncula lachrymalis
and the greater angle of the eye, can only be cured by extirpation. This is
an operation which the proximity of the sac, the conduits and puncta, as well
as the globe of the eye, renders very delicate. An assistant placed at the
back of the patient is charged with keeping the lids apart. The operator,
placing himself in front, seizes the tumor with a hook or a pair of forceps, and
dissects it carefully with the point of a sharp bistoury, first from below, then
within, then towards the eye, and then from above, penetrating as far as the
disease requires, and removing it as quickly and completely as possible. It
was thus that Marchetti detached a melicerous tumor that covered even a part
of the cornea ; but he had recourse to the scissors to complete the operation.
Orbital Cavity.
Lupi, encephaloid masses, &c., may develop themselves in the interior of
the orbit. The lachrymal gland sometimes acquires a considerable size in
passing into the scirrhous state. These various lesions, whose peculiar cha-
racteristics are, the projection of the globe of the eye from the socket, audits
inclination at the same time in a direction opposed to the side where the tumor
exists, most frequently require the extirpation of that organ. Yet, whenever
it is not itself implicated in the degeneration, we can save it. This is proved
by a beautiful operation of Acrel, and the practice of Dupuytren. An old
work of Daviel and Guerin, of Bordeaux, recently published, proves also that
the lachrymal gland had been often successfully extirpated by these two
surgeons. There are even osseous tumors that may be removed without
injury to the eye, either with a chisel and mallet or well directed traction, as
is proved by a fact related by M. Saltzen. The rules for the extirpation of
the lachrymal gland, or any other tumor in the orbit, must necessarily vary
with size, form, nature, and seat of the disease. If, for example, it were a
cyst, full of more or less liquid matter, it would be sufficient to pierce it with
a bistoury, and keep the cavity open by means of a tent of charpie. M.
Schmidt and Rutdhorlfer,who have often seen such cases, think that even a punc-
ture with a trocar is sufficient. Guerin, of Bordeaux, in endeavoring to extir-
pate the lachrymal gland, or a cancer, acknowledges that, after passing the lids,
he came upon a tumor filled with semi-liquid matter; he opened and emptied
it, and introduced a tent; and, in twenty-one days, the cyst came away.
Spry, who made a similar mistake in 1755, might probably have saved the
vision of the patient, if, instead of continuing the extirpation of the eye, he
had had the prudence of M. Guerin.
As to solid bodies, there are two methods of removing them : —
1. AcrePs Method. — The lid is to be divided through its whole thickness near
its base, in a direction corresponding to its natural curve, and over the most
projecting part of the disease ; an assistant separates the lips of the incision ;
then, with a narrow bistoury, directed by the index finger of one hand, the
surgeon detaches the tumor from the orbit, seizes it with a hook, dissects its
internal face so as to separate it from the eye with the finger of the cutting
instrument, and tries to turn it from its summit towards its base. Daviel
and Guerin followed this method with success. Although in one case the
tumor presented on one of its faces a groove moulded upon the optic nerve,
42
330 NEW ELEMENTS OF
and in another, the operation was followed by an enormous swelling of the lids
and high fever, they succeeded in preserving the sight. At first, we might
doubt if the lachrymal gland itself had really been extracted ; but Guerin dis-
sected one after an operation, and even made a plaster model of one, the original
of which he exhibited, preserved in alcohol, at the Academy of Surgery. It is,
besides, at the present day a well-known operation. Messrs. Todd, Lawrence,
and O'Beirne have recently practised it in England with not less striking
success than Daviel and Guerin. M. Mackensie's treatise acquaints us with
two other examples, and Warner as well as Travers has performed it. The
method they used, however, is not free from objections.
2. Another Method, — It seems to me that the end would be better attained by
prolonging, at the commencement, the external commissure towards the temple,
so as to enable us to evert the lids. Some experiments on the dead subject
have convinced me that by this means we may very easily expose the two
external thirds of the orbital circumference. This being done, the surgeon
separates the tumor which he wishes to remove from the bony cavity that
encloses it, by dividing the cellular tissue from its external face ; then dis-
sects down to its greatest depth, and detaches it, with the utmost caution,
from the muscles, the optic nerve, or the globe of the eye, and removes it with
the finger or hook. Occasionally the operation is followed by a swelling so
great, as to make the eye appear after three or four days as prominent as before ;
but this is not long in disappearing. In the space of from ten to thirty days
every thing assumes its natural position, and the cure is commonly complete.
Union by the first intention should not be attempted after either process,
because the cavity left in the orbit cannot be immediately filled, and because
the tissues which have been torn rather than cut, must unavoidably suppurate.
In one case in which the incision closed too soon, Guerin observed such
alarming symptoms, that he was obliged to destroy the cicatrix with a sound.
It is, therefore, sufficient to dress with a pledget, or tent of lint covered with
cerate, to draw together the incision of the palpebral angle, if such have
been made, and cover the whole with a pledget and compress supported by
the suitable bandage. When suppuration is established, the dressings should
be renewed every day. Injections are often necessary, and every thing
should be done to make the cavity fill from the bottom. If by cutting through
the lids the operation can be made more easy, it should be preferred, although
the deformity it produces be so much greater ; but unless the tumor has
acquired great size, this is not the case. In a case that fell under the notice of
Mr. Hope, a tumor of seven years' standing had so elongated the optic nerve,
that it was necessary after its removal to press the eye back into its place
with the hand, and maintain it there with a bandage. Success was neverthe-
less complete. In the case of a young woman who was utterly intractable,
Mr. Wardrop abstracted fifty ounces of blood in order to produce syncope,
during which he performed the operation with such facility and success, that
the patient on reviving could scarcely believe her eyes.
OPERATIVE SURGERY. 331
Art, A.'^Globe of the Eye,
§ 1. Foreign Bodies.
A gold or silver ring, the head of a long pin, a small roll of paper, an ear-
pick, or any other smooth and rounded instrument, is sufficient to remove the
various solid foreign bodies that remain loose beneath the lids ; but these will
not always serve for particles of metal, stone, wood, &c., which, having been
projected against the eye, become fixed. Then, if there be no fear of injuring
the eye, a quill cut into the form of a tooth-pick, or some other such instrument,
will often answer the purpose. In other cases we must have recourse to the
point of a lancet, and in some others, even have to use a pair of small forceps
or pincers. It is only in rare cases, when the particle of iron is scarcely at all
attached, that the magnet, recommended by F. de Hilden (who highly extolled
its success in the hands of his wife), can be advantageously employed. The
same may be said of a stick of sealing-wax or amber, for removing particles
of straw, chaft', &c. When an operation has been decided upon, an assistant
is charged with keeping the lids apart ; with the point of a lancet, or very
pointed bistoury, the surgeon isolates the foreign body from the cornea to a
certain depth ; then lays hold of it with a pair of fine and accurate forceps, and
removes it carefully for fear of breaking it. The subsequent treatment is
the same as that for an ordinary ulcer, or simple ophthalmia. It is an opera-
tion that presents little difficulty, requiring only address and great precision
in the movements. When the body to be extracted has sunk deep into the
coats of the eye, without penetrating into the chambers, we may almost always
succeed in removing it by means of the edge or point of a lancet.
§ 2. Pterygium.
When proper medicinal applications have failed to dissipate pterygium,
and it advances upon the cornea so much as to cause the loss of sight, it
should be removed with the bistoury or scissors. The division of the ves-
sels that supply it, as recommended by Beer ; strangulation by means of a
thread passed between the conjunctiva and sclerotica, which la Vauguyon
preferred ; and cauterization, have all been more than once successful ; but
as all these means are fallible, and more difficult than excision, they are gene-
rally abandoned.
To remove it, the operator takes hold of it with a pair of forceps at one
or two lines from its point. By drawing it a little towards him, as if to
detach it, he soon hears it make a slight crack like a piece of parchment.
Then it is easy to cut it away from point to base, or in the contrary direc-
tion, with a bistoury or small scissors. As the cornea but rarely regains
its transparency opposite the cut, M. Boyer recommends, I think properly,
that when its point has reached so far as the pupil, not to extend the incision
so far as that, but to excise only its posterior four-fifths. Emollient lotions
for some days, then such resolvent applications as are used in all the chronic
phlegmasiae of the eye, constitute the consecutive treatment.
When the pterygium is not very thick, Scarpa thinks it will be most fre-
SS2 NEW ELEMENTS OP
quently sufficient to excise a semilunar flap of it opposite the point of union of
the sclerotica and cornea, and that in other cases it should be destroyed
entirely ; but to escape a disagreeable cicatrix, that the point should first be
detached, and then the base, so as to terminate the operation in the middle.
But I do not think this last precaution of much importance, and the partial
excision, which I have tried three times, has always mailed. It is prudent in
every case to follow the advice of M. Boyer to forewarn the patient that, not
withstanding the operation, he may not be perfectly cured, because a kind of
opacity but too frequently follows.
§ S. Cataract,
1. History. — Although, from the days of Celsus (who was the first to speak
clearly concerning it) to the present day, it is known that but few cases of
confirmed cataract have been cured any other wise than by an' operation, yet
it would be wrong to deny absolutely the efficacy of all other means of treat-
ment. Those which occur upon scrofulous, scorbutic, or syphilitic subjects, or
are caused by an inflammation, or some other disease of the parts contiguous to
the eye, have more than once either spontaneously disappeared with the ori-
ginal disease, or from the influence of a well-directed local and general treat-
ment; of which Maitre-Jean, Callisen, Alberti, Gendron, Murray, Richter,
Ware, and many others have cited examples. Henbane applied to the eye,
according to Nostier, and a seton at the nape of the neck, with M. Cham-
pesme, have quite recently triumphed over cataracts very far advanced. M.
Dietrich recommends that it should be arrestftd in its development by repeated
puncture of the eye ; and M. Schwartz has cured three cases by means of
revulsives, &c. Like Messrs. Rennes, P. Delmas, and Manoury, I have seen
it disappear spontaneously. Messrs. Larrey and Gondret affirm that they
have obtained the same result from moxas, actual cautery, or ammoniacal
pomatum, applied upon different parts of the head, especially the sinciput; but
to judge properly of the value of these, it is necessary to have certain proof
that the alterations which have been made thus to disappear were true cata^- '
racts, and not that which is now known as the false cataract.
Although Galen and the Arabians had indicated the nature of cataract, some
centuries passed before it became generally known. The pellicle that con-
stitutes the disease is placed by Celsus between the iris and the lens ; on the
contrary, G. de Chauliac, G. de Salicet, &c., place it between the iris and
cornea. That which contributed most to maintain and propagate such errors,
was the generally conceived opinion that the lens itself was the seat of vision.
However, when Kepler showed, in 1604, that the lens was only a refracting
agent, a prompt revolution in favor of truth occurred on this point of surgery.
Gassendi, who wrote in 1660, as well as Palfyn and Mariotte, attributes to R.
Lasnier, or F. Quare, the honor of having first contended that cataract does
not depend upon an accidental pellicle, but upon the opacity of the lens.
Schellamer learned it of a surgeon of the Hotel Dieu. Brisseau, Mery, P. du
Petit, Borel,Tozzi, Geoffroy, Albinus, Bonnet, and Freytag, doubtless obtained
it from the same source. We owe to Maitre-Jean, however, the settlement
of the question beyond dispute. But in escaping from one error, surgeons
were on the point of falling into another. Instead of not seeing the cataract ^
OPERATIVE SURGERY. 3S3
in the lens, they nearly passed into the other extreme, of never seeing it any
where else. Ph. de la Hire, Freytag, Morgagni, had much difficulty in per-
suading the profession that this disease may also be produced by the opacity
of the capsule. It was reserved to S. Muralt, Didier, Heister, and Chapu-
zeau to put beyond question that it is always produced by the opacity of the
lens, of its capsule, or of the matter in which it lies, and not by either one of
these exclusively. From the highest antiquity surgeons have attempted the
destruction of cataract by certain instruments. Celsus even gives us to un-
derstand that, among the physicians of Alexandria, there were many, amongst
the rest a certain Philoxemes, who had acquired great skill in this particular.
2. Conditions. — If the cataract be simple, if it be situated in the chrystal-
line, or have contracted no adhesions to the neighboring parts, if the iris
retain its faculty of contracting and expanding, if the patient can still distinguish
light from darkness, if there be no inflammation either of the eye or within
the orbit, if there be no cephalalgia, catarrh, nor general disorder, if the eye
be neither too prominent nor too sunken, if the patient be not too much
advanced in years, if he be quiet enough to submit to all the necessary cares,
then the chances of success are as numerous as one can desire. When,
on the contrary, the patient is wasted with age, there exist nebulas of the
cornea, the pupil unchangeable, the bottom of the eye is of a greenish hue,
there are frequent or permanent deep-seated pains of the eye, and a chronic
ophthalmia, or some other chronic disease difficult to cure, and more or less
serious, exists in the neighborhood of the eye, then we should not count upon
success. In other words, whenever the lens and its capsule aldne are
diseased; when, except the cataract, the organ is in a natural state, and
when the orbit contains nothing that can prevent the restoration of vision ;
whether the cataract be true or false, lenticular, capsular, or capsulo-
lenticular, membranous, anteriorly or posteriorly, hard or soft, milky or
chalky, permanent or movable, star-like, pearly, three -branched or central,
purulent, putrid, spotted, or reticulated, marbled, dry or husky, bloody,
stony, yellow, brown, or black, the operation may be recommended. But
in other cases it should never be tried but as a last resort, and after notifying
the sufferer of the little chance of success. Still v/e should not be too much
alarmed by appearances. The immobility of the pupil is not more certainly a
sign of amaurosis, than its mobility is of a healthy state of the retina. Wen-
zcl, Richter, Larrey, Watson, S. Cooper, &c., have shown us that the adhesion
of the iris to the capsule of the lens, or the contraction of its opening after
iritis, can leave it immovable, as well as a paralysis of the retina can leave it
the contractile power. Certain subjects who could not distinguish day from
night, have, after the operation, recovered their sight. The black cataract
observed by G. de Chauliac, Morgagni, and Freytag, and of which Maitre-Jean
Pellier, Arrachard, Wenzel,Coze, Cloquet, and Riobehave given us examples,
is too rare, even supposing that it can exist without changing the tint of
the pupil, to arrest an intelligent operator. In a word, when no organic
lesion nor serious symptom renders the operation dangerous, I cannot see
why, if the patient be completely blind, we should refuse to attempt the
operation. The patient can lose nothing, and if he have but one chance in a
thousand of recovery, it would be inhuman to withhold that one. Neverthe-
less, we should absolutely abstain from operating wlicn there is a certainty
334 NEW ELEMENTS OF
of deep-seated alteration of the eye. In a man in this state, and to whose
entreaties I at last yielded, the lens escaped gently of itself, enveloped in its
capsule some moments after opening the cornea, when the vitreous humor
showed itself so fluid, that it would have escaped like water if I had not
instantly applied some compresses of lint upon the eye. Some cerebral
disturbances followed, and even so serious for several days .as to give me .
much inquietude. The left eye is filled with pus, and the right, although
perfectly clear, remains insensible to light. False cataracts, which are
almost always complicated with affections of the iris or some other membrane
of the eye, are less easy to destroy tlian the true ones. All things equal, the
cataract of the lens itself is not so bad as that of the capsule, or of the liquor
Morgagni. In children, although the operation is difficult, we succeed better
than in adults; and after tliat, in a ratio with the distance of the subjects
from decrepitude.
S. Ages. — Almost all authors think, with Sabatier, that the operation should
only be attempted on those who can know its utility, and that is, that it should
not be used before the tenth or fifteenth year for instance. The indocility of
children, the little desire they evince to see the light, the dangers to which
they are exposed in the attempt to operate against their will, and the diffi-
culty of making them submit to the necessary precautions. Are the principal
motives upon which this doctrine has been established. At the present epoch
it is not to be admitted. If the operation be more delicate and hazardous
in infancy, the membranes of the eye are also more tender, thinner, and '
less dense, and more easy to penetrate; the eye is less movable, the pupil
larger, and the subjects, fearing only the pain, do not trouble themselves about
what follows. As the operation is rarely attended with acute suffering, I can
see nothing very alarming in such cases. Besides, it is always possible to
confine the youngest subjects, and to separate their lids. The eye is an organ
essential to the development of intelligence, and the source of the greatest
number of ideas. If its functions are abolished from birth, its development
commonly remains incomplete; it acquires slowly an excessive mobility,
that renders the operation much more delicate, and lessens the chances of
success. In a word, when we think of its importance to the education of chil-
dren, it is really difficult not to admit, witli Ware, Lucas, Saunders, Travers,
Beer, and Jager, the necessity of destroying the cataract as soon as possible. <
Yet, I do not therefore think that we should choose the age of two years, as
Fame recommends, nor of six Aveeks, like Lawrence, rather than one or three
years. In old men, as the disease is almost always a natural consequence of
age, the operation is not permitted unless it be ardently desired, and the
patient be in other respects in the best possible condition. I have, however,
just performed it for a- subject eighty years old, with a success which we are
far from always obtaining in younger subjects.
4. Simple or Double. — When the cataract occupies but one eye, there are
some operators who object to operating. With one eye perfectly sound,
the subject, they say, sees almost as well as with two; well enough, at
least, to move about, read, and fulfill, in fine, all the duties that society re-
quires. In this case an operation might, by producing inflammation, affect the
healthy eye, as M. J. Cloquet has seen, and produce a complete blindness. ^^
But, provided it succeeds, the luminous rays not falling on both retinas 7"
OPERATIVE SITRGERY. 355
harmomously, the discordance is necessarily followed by confusion of vision.
To these reasons it may be objected, that if the healthy eye sometimes
inflames and is lost after an operation, it is an accident that but rarely happens ;
and that sight is undeniably better with two eyes than one, and that the
presence of a cataract on one side seems to have an agency in producing a
second on the other. . As to the difference which it was supposed would
exist in the field of vision, after tlie removal of the cataract, experience has
now demonstrated that it is not manifest. Maitre-Jean, Saint Yves, Wenzel,
&c., relate some observations in which they make no mention of it, al-
though they had under their care patients on whom they operated onlj
on one side. I have published some facts of the same kind, collected hi
the Hopital de Perfectionnement. M. Lusardi writes me that he possesses
many such ; and, in line, M. Roux, who has often extracted the cataract
when it existed only on one side, has not seen that the patients needed
any thing else after it than glasses of a different form for each eye. Con-
sequently, if the subject be young and healthy, and he urgently desires it, the
operation should be performed, although one of the eyes be perfectly sound.
Cataract commonly exists some time in one eye before completing itself in
the other. In this case, should we wait, or would it be better to operate as
soon as the first is completely formed ? Many recommend, that we should
temporize until the second eye distinguishes objects confusedly. They found
their advice upon the fact, that the operation may not be followed by
success, and may aggravate the state of the other eye so much, that the
patient will be worse after than before the attempt. But supposing it may be
successful, and, as has been often observed, this same eye should lose its
powers again after some years, the other treated in the same manner offers
another resource. I know not how far this reasoning may be good ; but this
is certain, that a cataract once formed cannot remain in the eye with impu-
nity, and that the subject of it in one eye has much difficulty of comprehend-
ing the advantage of waiting for the attainment of the same state in the other ;
therefore, if vision is so far embarrassed in the second eye as to induce the
sufferer to call upon us for our assistance, it would be inhuman, in my
opinion, to refuse it to him.
Formerly it was admitted that cataract passed through different degrees of
consistence ; that it was soft and diffluent at first, and became, slowly, firm
and solid ; in a word, that it could be ripe or unripe. It is now known that
cataract may be solid at the commencement, and become liquid after the lapse
of many years : the very reverse of what the ancients thought. Yet, it is not
the less true that the contrary is often observed, and that the idea of its matu-
irty or immaturity is not altogether without foundation. As it is almost always
the result of an internal morbid cause, cataract is really only complete, when
that cause ceases to act upon the eye, in which the opaque body holds the same
place as a necrosis in some other part of the system; that is, it becomes a
foreign body. It is not, therefore, because it is too soft or too hard, that it is
prudent to await its complete development ; but rather because, its progress not
being completed, there is less chance of success then than at a more advance^
period, when its formation is entirely finished.
Scarpa, M. Dupuytren, and many other able oculists, have advanced the
opinion that it is better, when a cataract occupies both eyes, to operate first
336 NEW ELEMENTS OF
on one side, and wait for a cure, before attempting it on the other. If it suc-
ceed, the patient may content himself with it, if the eye do not become too
weak ; if it fail, there is left another resource. The sufferer bears the second
operation more firmly than the first. When the two eyes are operated upon
at the same time, the inflammation of one almost always aggravates that of
the other ; reaction is more lively, and the risk of unpleasant consequences
much greater. Messrs. Boyer and Dupuytren observe on this subject, that
a double ophthalmia, once developed, rarely fails of fixing itself permanently
upon one eye, where, changed in some manner from what it was, it terminates
most commonly in the destruction of the organ. All this is somewhat doubt-
ful, and as the single operation, even in the happiest cases, but incompletely
restores the sight ; as patients prefer bearing the two operations in immediate
succession to leaving a long interval between them ; as an operation on the one
side sometimes determines inflammation on both, and as the double operation
offers numerous favorable chances for one, at least, if not both of the eyes, I
conclude, with Wenzel, Demours, Forlenze, Boyer, Roux,&c., that, all other
things equal, it is better to adopt the latter.
5. The Preparations to which the ancients subjected the subjects of this
disease, are almost entirely abandoned by the moderns. At present, a more
or less strict regimen for some days, venesection, some laxative or gentle pur-
gative, diluent drinks, or calming and anti-spasmodic preparations are em-
ployed, according as the patients may give signs of plethora, disorders of
the digestive functions, or excessive irritability of the nervous system. As a
means of preventing inflammation, some make use of a vesicatory, or some
other derivative, upon the skin. Scarpa applies it upon the nape of the
neck, fifteen days beforehand. M. Roux on the same place, just at the time
of operation. M. Forlenze preferred it upon the arm. I doubt if it be not
more dangerous than useful. Many operators dispense with it apparently
without disadvantage. Adopted generally, it must be often injurious. In
the first few days, it sometimes produces fever, heat of the skin, irritation,
and other consequences dangerous to the eyes. If it should be placed upon
the neck, then it would be well to follow the advice of Scarpa and Dupuy-
tren, who, when Ihey thought it appropriate, allowed an interval of fifteen
days between its application and the operation. Upon the arm, it is very evi-
dent that it may produce no inconvenience, but on the other hand, it does not
seem to promise the least advantage. As to myself, I use it after the opera-
tion, provided particular circumstances require it, nor can I see that this
plan offers any thing reprehensible.
6. ASert-so/is.-— -Spring and autumn have been chosen as seasons more favor-
able to the success of operations for cataract, than summer and winter.
These periods have certainly some advantages for the patient, but less on
account of the seasons, properly speaking, than because of the temperature,
which is commonly more mild and more regular then than in the other parts of
the year. Yet, as these conditions maybe met with or secured at all times, the
operation may, strictly speaking, be performed at any season. However, a
decision should be made with great care, if there exist any serious epidemic
at the time, especially if it affect particularly the mucous membrane. If
catarrhal affections, ophthalmias, measles, or even erysipelas exist, prudence
dictates that we should abstain from operating.
OPERATIVE SURGERT. 337
Methods of Operating,
The opaque lens is either depressed, that is, placed in such a situation that
it will disappear under the influence of the laws of the organization, or it is
removed entirely out of the eye. These constitute the two methods.
A. Depression.
The first method, known by the name of depression, is performed in different
ways. It takes the name of scleroticonyxis, when the needle is passed
between the iris and vitreous body ; hyalonyxis, when passed intentionally
through the hyaloid membrane, and that of ceratonyxis, when passed tlirough
the anterior chariber and cornea.
1. Preliminary Mentions. — On the eve of the operation, the patient, who
should have taken but very light food, should receive an injection, if his
bowels be not very free. An aqueous solution of the extract of belladonna
instilled between the lids of the eye an hour before, obliges the pupil to dilate
largely, allows us to follow with the greatest security every movement of the
needle, enables us to avoid the iris, and to push with less difliculty into the
anterior chamber some portions of the cataract, when it may be deemed neces-
sary. The irritation that the application produces is too slight to require
notice. The momentary paralysis which it causes soon disappears, without
affecting the functions of the organ. The advantages which it furnishes are
of the highest importance, and not to be sacrificed through any idle apprehen-
sions. With irritable or timorous subjects, whose eyes are very unsteady, it
is well to accustom the organ to the contact of foreign bodies ; touching it
frequently for several days with a blunt instrument of some kind, or with the
finger.
The Apparatus consists of two needles at least, so that if one fails us, the
operation may be continued with the other ; of a cap or band that will exactly
embrace the head ; a rolled bandage two or three ells long and two inches
wide, to secure the cap ; a long compress to cover the sound eye, whilst
operating on the other ; some oval pieces of fine linen, cut full of small holes,
to be placed over the eye after the operation, to prevent the lint from imme-
diately touching the lids ; a bandage, folded double, long enough to pass round
the head, and of from four to five fingers in breadth, offering at the middle,
near its edge, an incision like a T inverted, to receive the nose ; and a bandage
of black taffeta to cover this last; then a good sponge, warm water, and pins;
the whole to be disposed in the order in which they will be needed.
Instruments. — As it is more especially for extraction that the speculum,
V elevators, and ophthalmostats have been proposed, I shall say nothing of them
here. In the needle there is the greatest variety. That of Celsus was shaped
like a lance-head, straight, and two inches long. Later, a round one was found
more convenient. Then came the triangular form. In fact, almost every
operator has his own. Scarpa's, which is only eighteen lines long, is termi-
nated by a point a little enlarged and curved in the arc of a circle, plane on
its convex side, ground to a rounded edge, or rather ridge, on its concave
43
338 NEW ELEMENTS OF
side, and, like all others, mounted upon a handle, having on its back a mark
of a difterent color. M. Dupuytren rejected the kind of crest found on the
concave face of Scarpa's needle. He made his smoother on this side than oa
the back, so as to embrace the lens more securely, and not expose it to being
divided in the attempt to sink it to the bottom of the eye. He also recom-
mends that it should have less breadth, and that its shank should be slightly
conical, so as to keep the way opened by the point constantly filled, in order
to prevent the escape of the humor of the eye during the operation. The point
of the one adopted by M. Bretonneau, though short, is as large as that of
Scarpa's; its shank, of cast-steel, is more slender, and almost cylindrical,
and passes freely and without the least effort through the puncture of the
sclerotica. This is an advantage which M. Dupuytren's does not offer, but
which exposes the eye to lose some of its fluids. Beer's needle, which many
of the German oculists use, is straight and lance-shaped, differing from M.
Er-etonneau's in having its shank conical and thicker. Hey exhibited one
which was not more than ten or twelve lines long, approaching more the form
of a cliisel than that of a needle. It is a mere modification of Hilmer's, which
is conical, and its free extremity, flat, terminated by a semilunar convexity,
is the only cutting part. Its sides, straight and round, and its want of point,
render it difllcult to wound the iris in pushing it towards the pupil ; whilst its
flattened form renders the depression of the lens less embarrassing. But v/ith
this instrument it is almost impossible to destroy a membranous cataract, or
even to make a suitable opening in the anterior capsule for the escape of a
lenticular one; and as the laceration, for which the inventor more especially
intended it, can be very well effected with any other needle, there is no
reason for preferring this. Messrs. Gragfe, Langenbeck, Himly, Schmidt,
tNcC, have each modified the needle to suit himself. But that is not the dif-
ficulty. In the hands of a good operator all are good. Scarpa's, Dupuytren's,
and Bretonneau's as much so as the rest.
2. Operalion. — Up to the eighteenth century the patient was made to sit
astride of a bench. Bartii and Arnimann preferred to have him standing.
Poyet, A. Petit, and Dupuytren recommend the horizbntal position. In France
the subject is generally placed upon a firm and solid chair of medium height.
Beer recommends a stool, whilst Richter prefers a chair with a perpendicular
back. In England a musician's stool has the preference. There is nothing
settled upon this point. Although the horizontal position is evidently best,
yet the others may be used without inconvenience.
a. Ordinary Method. — The surgeon either places himself facing the patient
upon the same bench, Mdth his knees between the latter's thighs, and a pad to
support his elbow, as recommended by J. Fabricius, or standing, like Dubois,
Dupuytren, and many others, or seated upon a chair somewhat elevated, with
the foot upon a stool, and a cushion on the knee for the elbow, as prescribed
by Scarpa. If seated, we have greater certainty in the movements, because
the elbow is supported ; but standing we have more freedom and ease. The
operator, therefore, may be left to choose the position that best suits his taste
or address.
Some surgeons, dispensing with assistants, separate the lids themselves.
Barth operated in no other way. Mr. Alexander, who is much extolled for
his skill in this method in London, is surpassed, we are told, by M. Joeger, in
OPERATIVE SURGERY. 339
Germany. The thing is possible, no doubt; but neither tricks of dexterity
nor imprudent boastings make a rule. Nothing in surgery stands more in
need of an assistant than the operation for cataract. It is necessary that
he should have a light hand, comprehend perfectly every step of the opera-
tion, every movement of the operator, and have had as much previous practice
as possible. Placed behind the patient, he, with one hand, embraces his
head and brings it against his own breast for support, while he elevates the
upper lid of the eye with the other. If an instrument should be preferred
to uncover the eye, the double hook of Berenger, or the crotchet of som«
others, can be very well replaced by the elevator of silver wire of Pellier.
In general the finger is best, whether, as with Scarpa, it be used to elevate
and keep the free edge of the lid against the arch of the orbit, or whether, as
advised by Boyer and Roux, it be sunk to the posterior edge of this arch by
bending the last phalanx of the finger. By the latter method the lid is more
firmly secured, but the angle formed by the phalangeal articulation interferes
more with the operator, and the eye runs greater lisks of being compressed.
Forlenze was in the habit of drawing all the palpebral teguments towards >
the l)row. By this means the ciliary border and the tarsal cartilage are
raised as high as possible, and the skin escapes less easily from under
the pulp of the finger. A means more sure of preventing the latter is, to
place a little piece of fine dry linen between the finger and the integuments
to absorb the moisture of the two contiguous cutaneous surfaces. If the
patient be in a recumbent posture, the surgeon, placing himself on tlie right
side for the left eye, and on the left for the right eye, puts on the cap and fixes
it with the band ; covers the eye on which he is not to operate with a little lint
and the long compress, which is passed obliquely around the head. The assist-
ant, standing or sitting on a chair at the bolster of the bed, prepares himself
to elevate the upper lid. With the index finger corresponding to the diseased
side, the operator depresses the lower one and fixes the eye. With the other
hand he holds the needle in the manner of a pen ; carries the point of it per-
pendicular upon the sclerotica af a line and a half or two lines from the cor-
nea, a little below the transverse diameter of that part; turns its concavity
downwards, and one cutting edge towards the cornea, the other towards the
orbit, in order to penetrate by separating rather than cutting the wall of the
eye, inclines the handle at first downwards and forwards, and elevates it
again in the opposite direction as it passes into the posterior chamber ; the
last two fingers of the hand resting meanwhile between the parotid and cheek
bone. Before sinking the instrument any deeper, it is turned upon its axis so
as to present its concavity backwards, that it may pass without risk, first
under and then before the lens, penetrating inwards and forwards, without
touching the iris or the capsule of the lens, if possible, through the pupil into
the anterior chamber; then the point, with a kind of circular motion, is
applied repeatedly upon the anterior face of the lens, until its envelope is torn
up as completely as possible. This done, the surgeon applies the axis of the
needle upon the anterior face of the lens, pushes it with a swaying motion
downwards, outwards, and backwards into the depths of the eye, below the
pupil and the vitreous humor, where he holds it for half a minute to prevent
its disengaging itself; then withdraws the instrument gently by slight rotatory
movements; gives it again the horizontal position ; turns its convexity again
upwards, and withdraws it the same way it had been introduced.
340 NEW ELEMENTS OF
i?cmarA:5.— Several points in this operation merit particular attention. Ii
the needle be carried above the transverse diameter, as some operators propose,
it becomes almost impossible to depress the lens freely, or to avoid leaving it
more or less near to the centre of the eye. By applying it upon the external
extremity of this diameter, the surgeon cannot fail of wounding the long
ciliary artery, and producing an internal hemorrhage ; therefone the lower
point should be selected. When the convexity of the instrument is turned
forwards, as Scarpa recommends, the fibres of the sclerotica, as well as some
of the ciliary nerves and vessels, are necessarily divided ; while nothing of
the kind takes place if the preceding precepts are followed.
J. Fabrice taught that the needle should be entered at the junction of the
cornea and sclerotica. Others, with Purman, say a half line from the former ;
some at a line and a half; many at two, two and a half, and three lines.
There are some who say the breadth of the straw, the middle of the white of
the eye, &c. Those who prefer such a considerable distance, are fearful of
wounding the ciliary circle or processes. Among others, there are some, who,
like Platner, dread injuring the tendon of the abductor muscle, or the sixth
pair of nerves. The object of Fabricius in going so near the cornea was to
arrive more directly in front of the cataract, whilst most others are more
careful to avoid the retina. But as to the truth in this case, two tilings are
certain: that the pricking of the tendon of the straight muscle produces no
inconvenience ; and that the wounding of the retina is inevitable, when we
penetrate through the sclerotica, whatever may be the distance from the cor-
nea; it therefore follows as a general rule, that there is less danger in enter-
ing too far from, than too near to the ciliary bodies.
The object in view in turning the back of the needle forwards while it
passes under and before the cataract, and thence into the anterior chamber
through the pupil, is to preserve the retina and iris as much as possible from
the action of its point or edges. It is passed into the anterior chamber, that
it may give assurance that it is not entangled between the capsule and lens.
The tearing of the capsule is more delicate and more important than generally
imagined. It should be begun at the circumference. If it be commenced at
the centre, it will afterwards be very difficult to detach the shreds and prevent
a secondary cataract. The best plan is certainly to depress both the lens
and its capsule together, without any laceration, as some authors have recom-
mended ; but how are we to get a membrane so thin to the bottom of the eye
without dividing it, however slight its adhesions ?
To depress the opaque body, it is not sufficient barely to seize it with the
point of the needle. The concavity of the instrument must exactly embrace
it; otherwise it will become reversed with the least pressure, either upwards
or downwards. The depression once commenced, the needle becomes a
lever of the first kind, its fulcrum being the opening in the sclerotica; to
continue its action outwards, backwards, .and downwards, it is necessary that
the convex side of the point of the instrument should be gradually turned
upwards, at the same time that we are performing the other movements before
mentioned.
When the cataract is depressed, some recommend the patient to turn his eye
upwards and inwards, believing thereby, but erroneously, that the lens will
be sunk deeper. By not withdrawing the needle for some seconds, the com-
pressed cells of the vitreous humor are allowed to take theirnatural positiop
OPERATIVE SURGERY. S41
and imprison, as it were, the cataract, which would almost necessarily return
if it were left immediately. The slight rotatory movements that are given to
the instrument before withdrawing it, are intended to detach it with the
slightest possible disturbance of the lens, so as the more surely to leave that
body in its new situation.
If, in spite of all these precautions, the cataract rises again, it is necessary
to seize it anew, and to depress it more deeply ; continuing to do so until it
rises no more. If it be soft the instrument bursts it, and then it is but rare
that the whole is depressed below the pupil. In that case, if it be impossible
to carry the pieces backwards, the operator should endeavor to reduce it to
small morsels, and then force it into the anterior chamber, to be dissolved by
the aqueous humor and absorbed. Any opaque mass that may remain after a
depression of the lens, should also be carried there. This is easily done with
such portions as are completely free. This unhappily is not the case, however,
when we have to do with pieces of the capsule of the lens. Then practice
and address are requisite to pierce them, near the centre of their base, with
the point of the needle, and tear them, by rolling them on themselves or by
dragging them away. It is important to leave none such in the visual axis,
for their opacity will necessarily compromise more or less the success of the
operation. If the capsule adhere to the iris, it must first be separated, taking
as much care as possible of the iris. If any circumstance prevents this dis-
junction, we are reduced to the necessity of displacing the lens first, and
then to operate upon this portion of the capsule, as above directed.
If the cataract be milky, and the capsule be affected, as is almost always the
case, it is indispensable to carry the instrument to the centre of the pupil
before dividing any thing. Otherwise, the opaque liquid escaping into the
eye, clouds the humors and prevents the operator from seeing what he is
doing. Yet, if this inconvenience should occur, whether the needle were or were
not in the anterior chamber, he should simulate as exactly and with as much
prudence as possible the movements necessary to tear away all that may
require removal.
b. Process of Petit and Ferrein.' — At the beginning of the last century some
authors maintained, against Hecquet, de la Hire, &c., that the seat of the
cataract is always in the chrystalline lens, and not in its membrane. Petit,
the physician, adopting this hypothesis, thought of depressing the opaque body
without touching the anterior leaf of the capsule. After thrusting the needle
into the posterior chamber to attain his object, Petit inclined one edge out-
wards and backwards, by which means he opened the vitreous body, and then
carried it to the external, inferior, and posterior part of the capsule, which he
tore ; then grappled the lens and conducted it into the hyaloid body, conform-
ing otherwise to the general rules of depression.
This modification, which was revived some years after by Ferrein, who
claimed the honor of its invention, was afterwards defended by Henkel,
Gunz, Gentil, Walborn, &c. By leaving the anterior capsule untouched,
they expected to establish sight more perfectly than by the common method.
It was thought that by falling upon a convex membrane, the luminous rays
would scarcely perceive the absence of the lens ; that the accordance of the
focus of vision would be maintained, and that there would be no need of
glasses after the operation. To these reasons it was objected, that the capsule
34£ NEW ELEMENTS OP
itself was often tiie seat of the affection, either alone or conjointly with the
lens; that still more frequently it would become opaque after the operation,
and produce a secondary membranous cataract; and, consequently, so far from
attempting to save it, it should be as completely destroyed as possible ; and,
finally, that by depositing it in the vitreous humor, instead of depressing it,
the patient is exposed to serious accidents.
c. Process of the Jtuthor. — The last objection adduced by the adversaries
of Petit is the only one destitute of foundation. If the rupture of the vitreous
body be dangerous, the operation by depression could scarcely ever succeed,
for it is almost impossible to prevent this effect. If the lens be not drawn in
some manner, in spite of the operator, into the vitreous body, how would it
ever remain depressed, repulsed, as it would be continually by the natural
elasticity of the hyaloid membrane ? Besides, in passing it between the shell
and the humors of the eye, how can it be prevented from tearing the retina,
and making a havoc an hundred times worse than the incision of the vitreous
humor? Starting from this idea, M. Bretonneau has adopted the method of
Petit, with a slight modification ; that is, after forming a passage for the lens
in the vitreous humor, he tears it away from before as in the ordinary process.
Having witnessed the success of this method in the hospital of Tours, in 1818
and 1819, I have since used it on all occasions, and have never had cause of
regret. I perform it in the following manner ; the needle is directed as if to
pass behind the cataract; when it has penetrated about four lines deep before
changing the position, it is to be inclined downwards, backwards, and outwards,
in order to open largely the hyaloid mass ; the back is then turned to the
iris, and by elevating the handle, the point is made to pass under the inferior
edge of the lens, to be afterwards brought into the pupil ; the anterior leaf
of the capsule is then torn up, the opaque body seized and pushed with a regu-
lar swaying motion in the direction of a line from the great angle of the eye to
the mastoid apophysis on the same side. By this means we escape wounding
the iris ; the elasticity of the vitreous body, which is sometimes very great,
cannot offer the least resistance, and the cells of the membrane immediately
closing the passage, oppose successfully the reascension of the opaque body.
Hyalonyxis. — An itinerant oculist, Mr. Bowen, has published a pamphlet
in which he brings forward a method which he calls hyalonyxis, and which he
thinks preferable to all others. His aim is to traverse the vitreous body from
behind forwards, and downwards ; then open the posterior leaf of the capsule
and displace the lens, after the manner of Petit and Ferrein, without touching
the anterior portion of the envelope. To accomplish this, Mr. Bowen pierces
the sclerotica at four lines from the cornea; then pushes the needle towards
the cataract, behind which he stops ; breaks open the capsule, without going as
far as the pupil ; seizes the opaque body and buries it among the cells of the hya-
loid sac, using the instrument throughout as a crotchet or lever. The results,
according to the book, are highly favorable to hyalonyxis, scarcely averaging
two failures in twenty cases. From it we may, at least, conclude that there
is little danger in wounding the retina and vitreous bo.ly. For the rest, I see
no advantage in going so far from the cornea, nor need I reiterate the incon-
veniences of leaving undestroyed the anterior support of the lens. Besides,
nothing prevents us from preserving it by the method I have already indi-
cated.
OPERATIVE SURGERY. 343
Scleroticotomy. — Some years ago, I scarcely know why, M. Gensoul intro-
duced a strange operation, which he soon after abandoned, but which M. lloux
has thought proper to attempt at La Charite, in Paris. The original idea
belongs, I think, to B. Bell. A small incision is first made behind the iris, at
the junction of the sclerotica with the cornea; through it the surgeon intro-
duces a kind of curette before the lens, depresses that body, and the operation
is finislied. The only advantage of so large an opening of the sclerotica,
would be in remedying more easily than by a simple puncture a too great
fullness of the eye. But the division of the ciliary body, the possible escape
of the humors, and the impossibility of carrying the cataract far enough
back, are* sufficient a priori to make us reject it, if even the attempts of its
inventor, and of M. Roux, had not shown its inconveniences and dangers.
/. Retroversion or Reclination. — After Pott, some English and German ope-
rators, Willburg and Schifferli among others, have advanced the idea, that
instead of depressing the lens it would be better to turn it over. It cannot
be denied that this modification renders the manual part of the treatment
more simple and easy. After the anterior capsule has been torn, it is siifii-
cient to apply the needle a little nearer the upper than the lower edge of the
lens. Then, by pressing upon it, the lens is instantly turned upon its trans-
verse axis, its anterior face being upwards, and its superior edge behind. But
if the opaque body is to be carried, besides, into or under the vitreous humor,
as recommended by Beer, Weller, &c., this operation is then evidently
changed into the ordinary one; whilst, if it be left below the centre of the
pupil, in the posterior aqueous chamber, it is clear that in most cases it will
either rise again, or produce such irritation of the iris and the rest of the eye,
as to occasion the most serious consequences.
g. Cutting or Breaking up of the Lens. — After demonstrating that when
once in contact with the aqueous humor, the lens is dissolved and finally disap-
pears. Pott wished also to prove that it is not indispensable to depress it below
the visual axis, but that, as Warner had advanced, to reduce it to fragments,
or even to open the capsule, was sufficient to destroy the disease. Experi-
ence has often confirmed this idea; for the examples of dissolution and absorp-
tion of a whole or a divided lens are not rare. As this method removes the
most delicate portion of the ordinary operation, it is not strange that many
oculists have adopted the opinions of Mr. Adams, who recommends it in all
cases. Yet I would say the same of it as of retroversion. It may be used
when the cataract is soft or too difficult to displace, but, in spite of the eulo-
gies of M. Parmi, it is less certain than depression, properly so called. If it
be true that the fragments of the lens sometimes dissolve very rapidly, it is
equally true that they often persist for many months, and even indefinitely,
thereby preventing the restoration of sight. If there then be less injury done
the vitreous humor, it is less easy to escape injuring the iris. Supposing there
are some advantages in leaving the cataract to be slowly dissolved, they are
counterbalanced by the inquietude of the patient, and the loss of time between
the operation and the restoration of vision.
To execute this operation any needle will serve ; but that of Beer, or the
small needle of M. Lusardi, in the form of a pruning hook, seems better than
that of Hey, Dupuytren, or even of Scarpa or Bretonneau. Although the lens
may be broken up from its posterior face, it is as well to prefer the anterior.
344 NEW ELEMENTS OF
that we may more surely see what we do, and more certainly avoid the iris. In
this direction, when the instrument reaches the pupil, and when the capsule
is sufficiently torn, the lens is cut into two parts by the point and edge of the
instrument, and these again divided into as small fragments as possible, the
largest of which we endeavor to push into the anterior chamber. When the
operation is performed through the posterior face of the capsule, and with a
straight needle, the breaking up is really more easy, because the anterior
lamina of the capsule remains entire, and because the lens, enclosed as it
were in a sac, is unable to escape the action of the instrument; but the vitre-
ous humor suffers much more than by the other process ; and, besides, it is not
uncommon to pierce, at the first motion, through and through the lens and its
envelope.
h, Tlie Lens passed into the Anterior Chamber. — At the moment of the ope-
ration the lens may slip through the pupil into the anterior chamber, in conse-
quence of some movement of the operator or the patient. It also sometimes
gets there in consequence of a blow, a fail, jolt, or any thing that can jar the
head, or produce i/Ii any way the rupture of the capsule. This accident does
not, however, oblige us absolutely to operate by extraction, as some have
thought, to remove the displaced disc. As it passed the pupil to get into its
new position, it certainly may be made to repass it into the old one ; and it
would always be more agreeable, to both operator and patient, to finish the
operation whilst the needle is in the eye, than to withdraw, and complete the
operation by incision of the cornea. In cases where nothing has been attempted
before the accident, it is no obstacle to depression, if the pupil remain dilat-
able, and there be very little inflammation. M. Dupuytren and Lusardi have
used the ordinary needle in such cases, passing it through the sclerotica and
pupil into the anterior chamber, securing the lens, opaque or not, and then
returning with it into the posterior chamber.
t. Ceratonyxis. — Depression, retroversion, and breaking up of thelens,which
are commonly performed by scleroticonyxis, or sclerotico-hyalonyxis, are also
sometimes done by ceratonyxis ; that is, by penetrating through the transpa-
rent cornea. This method, which many moderns claim the honor of invent-
ing, is far from being new. Avicenna speaks of some operators who first
opened the cornea, penetrating from thence to the lens, which they then de-
pressed by means of a needle which they called al-mokadachet. Abul-Kasem
says, positively, that he had followed this method. Manget also gives the
history of an English woman who cured the cataract by piercing the cornea.
In Haller's collection a thesis is found, defended by Col. de Villars, in which
this mode of operating is much extolled. It is thus, says the author, that birds
recover their sight, by sinking a thorn into the eye; and, according to Galen,
a goat pointed out to man the method by which he should operate for cataract.
In the eighteenth century Smith revived the operation of the Arabians. ' Der-
dell, the disciple of Woolhouse, imagining that the cataract was almost
always membranous, recommended to pass through the cornea to the anterior
lamina of the capsule, and to remove thence a circular disc, leaving a sort of
window for the passage of the light. Taylor and Richter have frequently
performed ceratonyxis in cases of milky cataract. Gleize, in France, and
Conradi, in Germany, spoke of it in 1786. In 1785 Beer had tried it twenty-
nine times. M. Demours had recourse to it in 1803; the epoch at which
OPERATIVE SURGERY. 345
Reil called public attention to it, and gave it the name it now bears. But the
united efforts of Buchorn, from 1806 to 1811 j of Langenbeck, from 1811 to
1815 ; of Dupuytren, Guille, and Walther, in 1812; Wernecke, in 1 823; Textor
and Pergin, in 1 825, were necessary to give it a place among the regular
operations I
The patient and assistants are placed as if for scleroticonyxis. A needle,
such as Bretonneau's, for example, or Langenbeck's, which is sharper and
with less extent of cutting edge, is presented at about one line from the scle-
rotica, and, supported by the back of the finger that depresses the lower lid,
sunk into the anterior chamber through the inferior and external part of the
cornea, reaches the pupil. The operator now turns the concavity of the instru-
ment downwards, having until then held it in the opposite direction to escape
the anterior face of the iris ; opens the capsule freely, detaches the lens, catches
its superior edge, and pushes it down and turns it backwards, and endeavors
to sink it below the pupil into the vitreous humor, or what is better, breaks it
up, and depresses the principal fragments when they cannot be drawn into
the anterior chamber. He then turns the back of the needle again downwards,
and withdraws it in the same manner that it was introduced.
Remarks. — Ceratonyxis must not be attempted until the pupil has been
made to dilate as much as possible ; and even then it is very difficult to
avoid pulling its borders while we seek to depress the lens. It is to escape
this inconvenience, and especially that of pricking the iris, that amongst us
the straight needle has been proscribed, and that we penetrate at some dis-
tance from the sclerotica, taking care not to go too near the centre of the
cornea. Neither the pyramidal needle of Beer, the shoulder which Graefe
has added to the ordinary needle to prevent its penetrating too far, nor the
needle of Himly, Schmidt, &c., offers, in reality, any advantage over those
commonly used in France, nor merits further notice. In animals this method
is preferable to all others, for reasons that need not be pointed out. Although
in the human species it may, strictly speaking, be employed whenever de-
pression would be proper, yet it should be chosen only for the milky cataract
with children ; with intractable persons, when the eyes are very movable,
irritable, or deeply sunk. The same hand may be used on both eyes. There
is no risk of dividing nerve or vessel. The retina is untouched. The iris is
not more endangered than by the posterior method. The tissues traversed
have little sensibility, and the membrane of the aqueous humor that Wardrop,
Langenbeck, and Chelius appeared to fear so much to wound, enjoys but a
very feeble vitality. The operation is therefore but a simple puncture, and
may be repeated a certain number of times without serious inconvenience.
But to these advantages may be opposed defects not less numerous. Adhe-
sion of the capsule, contraction of the pupil, flatness of the cornea, projec-
tion of the iris, hard, chalky, or stony cataract, seem all unsuited to its appli-
cation. Properly it is only for breaking up or retroversion of the lens, that
this method should be used. Although it has succeeded seven times in eight
in the hands of M. Textor ; although it has failed but twenty-six times in
three hundred and forty five cases with M. Walther ; once in six times with
M. Dupuytren, and four times in one hundred and twelve cases with M. Lan-
genbeck, still it has been abandoned as a general method even by its warmest
partisans. It is, in fact, incapable of replacing scleroticonvxis, which alone
44
846 NEW ELEMENIS OF
permits us to carry the lens, without extraction, out of the visual axis and
permanently to fix it there ; therefore this method can only be considered one
of exception.
j. As to the simple puncture of the cornea, formerly performed by Lehoe,
and more recently by Wernecke, for the purpose of favoring the absorption
or dissolution of the cataract, there is not enough proved in its favor to entitle
it to be formally recommended. Nevertheless, if, as cannot be doubted, the
decomposition of the lens, separated from its capsule, is a phenomenon much
more chemical than vital, we cannot see why the evacuation of the aqueous
humor, saturated with the anomalous substance, would not favor the disap-
pearance of the cataract by permitting the solvent to be renewed. Such a
practice seems to me applicable only to the consequences of ceratonyxis and
breaking up of the cataract; that is, v/hen a greater or less portion of the
opaque body remains out of the posterior chamber without disappearing.
k. In Children. — In early age we can scarcely think of operating by extrac-
tion. Then the evacuation of the eye could scarcely be prevented, as has
been proved by Scarpa, Ware, Saunders, Gibson, M. Lusardi, &c. Both
congenital and accidental cataracts in young subjects are almost always liquid
and membranous. Consequently there is nothing to depress or to extract.
The object to be accomplished is to lacerate the anterior leaf of the capsule
as completely as possible, and to evacuate it of tlie matter it encloses. It is
then almost immaterial whether we operate by ceratonyxis or scleroticonyxis,
at least when the pupil is large, as it commonly is in such patients.
The most difficult matter is to hold the patients. Ware laid them upon a
table, their heads elevated with pillows ; held them in that position by the aid
of assistants, and fixed the eye with the fingers, whilst another person elevated
the upper lid by means of Pellier's elevator. Gibson gives first an opiate ;
then secures the refractory in a sort of sack open at both ends, which is closed
by draw-strings above the shoulders and below the feet. M. Lusardi finds it
more convenient to set them upon the angle of a table, after having secured
the arms around the body; placing their legs between the thighs of the ope-
rator. The head and the rest of the body is held by assistants. Then with
one hand, furnished with a speculum which he calls contentive, M. Lusardi
fixes the eye and holds apart the lids, whilst he uses the needle with the other.
Whether we penetrate through the cornea or sclerotica, it is always necessary
to produce a true loss of substance in the anterior lamina of the capsule, and not
a mere rent, if we would avoid the risk of soon seeing a secondary cataract.
If the lens possesses much consistence, or if it appears necessary to tear up the
capsule, we must, as for the adult, sink the fragments into the vitreous humor
or carry them into the anterior chamber, where absorption operates more
promptly than behind the iris. At tlie end of fifteen or twenty days, if there
remain any opaque portions at the place of the lens, Ware recommends us to
repeat the operation. He is said to have practised four or five times upon the
same child with ultimate success. Such a plan should be followed, if the
operator is convinced that the fragments of the cataract cease to diminish.
Perhaps this would be a proper case to try Wernecke's method of evacuating
the aqueous humor by means of a puncture of the cornea.
When instead of the left eye, as I have heretofore supposed, we operate on
the right, the left hand should be used, unless it be in ceratonyxis, where.
OPERATIVE SURGERY.. 547
as we have seen, this precept is not necessarj. If both eyes be aflected,
as soon as the operation is finished on the first, it is to be covered with the
bandage which till now has covered the other, and that is immediately to be
treated in the same way as the first.
Consecutive Treatment, — When all is finished, the patient is desired to hold
the lids lightly closed. The practice of presenting some object to be assured
of the result of the operation should be abandoned. By suddenly reaching
the bottom of the eye, the light irritates the retina too much, and the proof
is only necessary to satisfy a vain curiosity. Especially when the needle is
employed it entirely fails of its object, for the disturbance which has just been
produced in the ocular chambers will render sight at first very confused,
although it may subsequently become very good. No one at the present day
would think of following Purman's advice of applying a small piece of gold-
leaf upon the puncture of the sclerotica, with the intention of preventing the
escape of the aqueous or vitreous humor. Brandy and the white of an egg,
employed by the ancients, and a thousand other topical applications, extolled
without cause, are' equally rejected. It is sufficient to dry the lids with a
sponge or a fine compress, and then place over the eye an oval piece of linen
cut in holes, dry or covered with cerate, and over that a soft fold of lint, a
bandage with a T incision for the nose, and secured behind with pins to the
cap ; and finally, the taffetta bandage, which covers the whole. It is im-
portant that none of these pieces should be so tight as to compress the contents
of the orbit. It would even be better, perhaps, to imitate Ware, who applied
a simple piece of linen to the eye, and proscribe, as some others do, every
thing that could embarrass the head. In no case must the subject be allowed
to make any effort or movement. He is to be carried to bed, and laid upon
his back, his shoulders and head raised with pillows. He is to be surrounded
by dark thick curtains so as to prevent the ingress of light, and recommended
to the most perfect repose of mind and body. He must be allowed only light
soups for three or four days. If the bowels be not regular, glysters, or even
laxatives, should be given. He may be allowed relaxing drinks, such as whey,
barley-water, veal soup, decoction of tamarinds, and the like. Bleeding must
be used upon the occurrence of fever, or when pain in the head indicates it. When
nausea or vomiting comes on, laudanum in the dose of a demigros in an
injection, as recommended by Scarpa, produces a happy effect. In ordinary
cases the infusion of linden, violet, or poppy, sweetened with syrup, are the
drinks commonly used. Insomnia and nervous agitation are combated by
an ounce of syrup of poppies in a julep. When no serious consequences
have followed the operation, the eyes may be uncovered on the fourth
day. The patient begins by sitting up. The linens being removed, the lids
are moistened and cleansed by the patient himself, with a piece of sponge
and warm water. As soon as they are dried the patient may open his eyes,
the curtains being carefully closed at the same moment. When the pupil
shows well, it is not prudent at that time to inquire further into the restoration
of sight ; the dressing is to be renewed each day in the same way as for simple
ophthalmia, as long as the eye continues red. If every thing goes on well, a
little more light every day is admitted to the eye, so that at the end of from
twelve to twenty days they may be uncovered entirely, except a shade of colored
taffeta. The diet need not then continue so strict, and in the course of the
348 NEW ELEMENTS OF
second week the patient may be allowed by degrees to resume his usual regi-
men. If it be otherwise, it is necessary to attend to the symptoms which
present themselves ; using appropriately either bleeding, local or general, pur-
gatives, revulsives, or such collyria as would be suited to the same kind of
disease produced from any other cause.
B. — Extraction.
Cataract was as yet but imperfectly known, as to its nature or situation,
when its removal was first undertaken. Antylus, according to Sprengel,
opened the cornea, and seized the opaque pellicle through the pupil, in order
to extract it by means of a needle. Lathyrus operated in the same manner.
Ali-Abbas and Avicenna speak of extraction as a customary method. Abul
Kasem says he learned of an inhabitant of Irack, that in that country they
introduced into the anterior chamber a short needle, which served to pump
the cataract. Avenzoar and Iza-Ebn-Ali, who rejected it, assert that in
their time exti'action was customary in Persia. G. de Chauliac himself has not
forgotten it, and Galeatius, the commentator on Rhazes, who extols it highly,
represents himself as the inventor. Completely unknown to, or abandoned
by the authors of the middle ages, this method of operating seems not to have
been restored to practice until towards the close of the seventeenth or com-
mencement of the eighteenth century. In 1694, Freytag opened the cornea
after the manner of the Arabians, and then drew from the eye an opaque mem-
brane, which was doubtless the anterior leaf of the capsule of the lens. Wool-
house passed the anterior chamber with a needle so constructed as to be
susceptible of transformation at pleasure into forceps, which served him for
seizing the opaque body and abstracting it. Petit, performing in the presence
of Mery the extraction of a cataract which had fallen into the anterior cham-
ber, surprised his assistants by showing them an opaque lens instead of the
pellicle they expected to see. Saint Yves attempted to extract the lens, but
without success, which induced him, we cannot see why, to maintain more
strongly than ever that the cataract has not its seat in the body of the
lens.
Yet these various attempts had scarcely fixed public attention, when Daviel,
in 1748, submitted his new method to thejudgmentof the academy, endeavor-
ing to prove that extraction is infinitely preferable to depression. With a broad
flexible lance-shaped needle he opened the inferior part of the cornea, and
then enlarged the opening by means of another needle, smaller than the first,
cutting on both sides, or with a pair of small curved scissors. A spatula of
gold to separate the lips of the incision, a needle of the same metal to oj)en
the capsule, a curette to favor the escape of the lens or its integuments, were
also necessary. The lens having fallen into the anterior chamber, he was
"bliged to put his plan in use for the first time, in 1745 ; after that he entirely
renounced depression. One hundred and eighty-two successful cases out of
two hundred and six operations announced to the academy, made a lively
impression there, as well as upon the public generally ; and although Caque,
of Rheims, could report but seventeen completely successful cases out of
thirty-four operations, each of them was eager to repeat his attempts.
Pallucci, who pretended, in 1752, to have practised extraction before Daviel,
OPERATIVE SURGERY. 349
opened the cornea from the less to the greater angle with a knife, the point
of which, being considerably elongated, r'esembled a sort of needle. Pojet
invented a narrow instrument, pierced near the point so as, in traversing the
eye, to pass a thread suited to sustain this organ while he completed the flap
of the cornea. La Faye proposed to supersede all the instruments of Daviel
by a knife in the form of a lancet, a little straightened, slightly swelled on one
of its faces, the back dull almost to the point ; he added a cystitome — a kind
of triangular pike supported by a spring, and inclosed in a sheath swelled in the
middle so as to resemble the body of a syringe. Soon after Berenger modi-
fied the ceratotome of La Faye, giving it greater breadth ; he made one side
plane, the other convex and much thicker towards its back. Siegerist gave
still greater length to the point of the knife of Pallucci, in order to open the
capsule whilst crossing the anterior chamber. But Jung has well remarked,
that a cataract needle is the best cystitome. At tiiis juncture in the state of
the professional mind upon the subject, appeared Richter, in Germany ; Wen-
zel, in France; and Ware, in England; who have decisively established the
rules for extraction.
Operation. — Two methods have been proposed for extracting cataract. One,
little known in France, is called scleroticotomy ; the other, almost the only
one used, is called ceratotomy. The same preparations are applicable to both.
The dressings are similar to those necessary for depression. Nevertheless,
the position of the patient, the assistants, and the operator require precautions
a little more minute than in the latter method. It is for extraction especially
that Richter and Beer insist upon the necessity of a solid and vertical back
to the seat, against which it will always be more easy, they say, to maintain
immovably the head of the patient, than against the breast of an assistant..
The horizontal position, proposed by some one, boasted of by Rowley and
Pamard, and which appears to offer, in fact, some advantages, by rendering
it less easy for the humors to escape at the moment of the operation, is, how^
ever, but rarely preferred ; no doubt because it is somewhat embarrassing to
the surgeon. I have tried it twenty-five times, and I must confess I have not
been able to comprehend why it has not been more frequently used. In
operating in this way it is necessary for the surgeon to place himself on the
side of the affected eye. But if the patient is to be seated, it is then, if not
indispensable, at least more convenient for the surgeon to operate standing
up before him than seated.
The speculum invented by F. de Aquapendente, afterwards used by Sharp,
modified by Heister, De Witt, &c. ; the ring of Bell and Assalini, which M.
Lusardi has mounted on a handle and reproduced under a new form ; the ele-
vators of Sommer,and all other instruments invented to separate, raise, or de-
press the eyelids — ^useful if we have not suiSlciently adroit assistants — are ad-
vantageously superseded by the fingers. Almost all are liable to compress and
empty the eye. The same may be said of theophthalmostats, amongst which
may be distinguished the forceps of Ten-Haaf ; the pike of Pamard, which
latter Casamata curved into the form of an S, that it might better accommodate
itself to the nose — which Rumpelt fixed upon a tliimble, that he might use it
with the middle, whilst the index finger of the same hand pressed down the
inferior eye-lid, and which Demours wished still further to modify by mount-
ing it on a thimble open at both ends. Yet I do not know that the trefoil of
S50 NEW ELEMENTS OF
M. Pamard, such as the grandson of. the inventor represented it to us, in 1825,
really merits the reproaches that have been cast upon it. Its point, a line and
a quarter long, is limited by a transverse shoulder-piece. Curved in such a
manner as to be applied without pain to the nose, its shank is mounted upon
a handle, which is seized in the same manner as a pen in >vriting, so as to force
with one hand the point into the cornea, one line from the sclerotica, at the
same time that with the other we carry the knife to a point diametrically op-
posite, at one half of a line only from the circle of the iris. The inventor
intended, very correctly, that these two instruments should be applied and
withdrawn together. In this manner we could operate with the same hand
on both sides, and I can conceive that a great deal of practice, and a perfect
accordance in the action of the trefoil and the ceratotome, could render such
an instrument much more useful than is generally imagined. I find it less
dangerous, for example, than the two fingers of the assistant and the operator
placed at the larger angle of the eye, as directed by Ware, to prevent it from
rolling inwards, and to compress it until the moment the knife finishes the flap
of the cornea.
1st. Sderoticotomy. — After experiments on the dead body, B. Bell asserted
that it was possible to extract the cataract by the sclerotica as well as through
the cornea. This idea, which Earl was the first to practise on the living sub-
ject, being revived by L. Lebel, has been definitely adopted by M. Quadri,
of Naples, who founds upon it his new method — sderoticotomy. An incision
three lines long is first made witlf any ceratotome whatever upon the sclero-
tica, two lines from the cornea. The lens and its envelope are then seized
by means of a small pair of forceps, and the whole removed by the external
angle of the eye. Pursuing this plan, M. Quadri affirms he has had but four
unsuccessful cases out of twenty-five operations. The first step of this is
less delicate, and perhaps less exposed to immediate accidents, than the same
in the ordinary methods. It cannot be very diflicult to seize the cataract ; but
liow is it to be held so surely as to make it pass through the opening without
great danger of emptying the eye ? How can we believe that so large an inci-
sion of the three principal tunics of the eye will not be most frequently
a-ccompanied by internal hemorrhage, by wounds of ciliary nerves or vessels,
and be followed by consequences much more serious than those which succeed
liie opening of the transparent cornea ?
2d. Ceratotomy. — Extraction, properly so called, is divided into three prin-
cipal steps : the incision of the cornea, the opening of the capsule, and the
expulsion or extraction of the lens. The instruments used for effecting it
have been greatly varied, and are as yet far from being the same in the hands
of all operators. In France the knife of Wenzel is in common use ; it differs
from that of La Faye only in having its faces alike and perfectly plain. Some
operators, however, prefer the ceratotome of Richter, the blade of which,
being very sharp, enlarges gradually from the point to the handle, so that it
can cut or divide one half of the circumference o§ the cornea, whilst crossing
the anterior chambei-. That of A. Pamard resembles the half of a myrtle
leaf, and has on its superior edge, which is straight and dull, a small rib to aug-
ment its strength. The knife of Ware, generally used in England, is almost
similar to that of Richter, and the instrument of Beer, so much boasted of
ifi Germany, differs from it only in the greater breadth of its point and some-
OPERATIVE SURGEUY. S51
ivhat less length of blade, which is also a little broader. Berenger has pro-
posed an instrument, convex on one side, plane on the other, and a little wider
than that of La Faye. Lobstein widened it still more, and lengthened the
point. With this form, its convex face turned behind protects the iris, whilst
its plane face glides verj easily behind the cornea. Slightly modified by B.
Bell, this knife has since been improved by Jung, one of the ablest cotempo-
raries of Beer. According to Sprengel, the ceratotome of Jung, convex on both
faces and cutting with both edges, is very short, and a little broader than is
necessary to divide at one cut the semicircle of the cornea. On the contrary,
according to M. Harel, it should be, like that of Lobstein, convex only on its
posterior face, and resembling a sort. of guillotine. Finally, that of Barth is
distinguished from the preceding by the furrow which it presents near the
back, on one of its faces.
In the midst of such abundance, the most important matter is the selection
of an instrument of such form and dimensions as will permit the complete
division of one half of the cornea, whilst traversing in a direct line the an-
terior chamber, and without permitting the escape of the aqueous humor
before the completion of the incision. To accomplish this object, its blade
must be of a triangular form, one inch long, three lines wide at the heel,
slightly convex on both sides, a little stronger towards its back than towards
its edge, and becoming thicker by degrees from the point to the handle.
Accordingly, the knife of Richter, a little shortened, as Beer recommended,
appears to me preferable to all others ; to that of Wenzel in particular, and
even that of Lobstein, as modified by Jung. Yet it is evident, that in a case
of absolute necessity, we might accomplish our pui^ose with a simple lancet,
the little hooked knife of Sharp, a sharp bistoury, or, in fine, with an instru-
ment of almost any kind. We therefore speak of what is most convenient,
not of what is absolutely necessary.
The second step in the operation has also given much exercise to the indus-
try of surgeons. The needle of Thuraud, the lancet of Tenon, that of Hell-
man, Durand, and Grandjean, the stylet of Mursinua, the cystitome of La
Faye himself, with or without the modifications of Rey, are generally aban-
doned. The hook of Boyer would have fallen into equal desuetude, if the
curette of Daviel, which is yet sometimes used, were not mounted with it
on the same handle. The new cystitome proposed by M. Bancal, founded
on the same principles as that of La Faye, from which it differs, however, in
the flattened form of its body, and in incising the capsule from the greater
towards the smaller angle, in a semilunar direction,. and not by a simple
puncture, will probably share the same fate. The reasons urged in its favor
do not prevent the substitution of the point of a ceratotome, or a common
needle. A straight and delicate forceps, carrying a hook at the end, like
that of Reisenger ; the straight forceps of Blemer; or the toothed forceps of
Beer — such ocular forceps, in fine, as may be found at any cutler's — a crooked
needle, a small spatula or curette of gold, and the syringe of Anel, which
may be useful for detaching or bringing away some of the shreds of the cap-
sule or pieces of the lens, after the extraction — may also be placed with the
knife and the needle beside the operator.
a. Inferior Keratotomy. — First Step. — Tlie patient and the assistants being
placed as for deoression, the surgeon draws down the inferior eye-lid with the
352
NEW ELEMENTS OF
index finger, which he applies at the same time upon the caruncula lachry-
malis, in order to sustain the globe of the eje on the inside ; then seizing the
cataract knife with the other hand, and placing the point at a half line or a
line fi'om the sclerotica, and resting the end of the little finger on the temple,
he pushes the knife without hesitancy into the anterior. chamber, perpendicu-
larly to the axis of the cornea, a little above its transverse diameter, and
from the side of the external angle of the eye. Immediately after, he in-
clines the handle of the knife backwards, without which precaution the point
could not fail to wound the iris, and pushing it horizontally, with firmness,
to the point of the cornea directly opposite, until it pierces it .again from
within outwards, urges it forward in this same line without pressing upon its
cutting edge ; taking care never to turn it outwards, but keep one of its faces
exactly parallel with the anterior face of the iris, whilst the other looks
towards the front of the eye, until, by the continuance of its progress, it has
entirely divided the inferior half circle of the cornea as near as possible to
the sclerotica ; that is to say, at a line, or a half line from the great circum-
ference of the iris. At the moment the knife terminates the section, the least
pressure would be extremely dangerous, requiring, consequently, the greatest
caution to avoid it. At that instant the assistant must let go the eye-lid,
which the patient, to whom are accorded some seconds to recover his self-
possession, closes gently.
Second Step. — After having gently wiped the region of the eye, the sur-
geon, or the assistant, raises a second time the upper eye-lid, taking great
care not to touch the globe of the eye, and presenting, with the other hand,
the back of the cystitome of Boyer, or a cataract needle, at the lowest point
of the incision, he penetrates from thence through the pupil at its upper
part, and carries the instrument from one side to the other in such a manner
as to divide the envelope of the chrystalline freely with the point of the
instrument, the concavity of which should be kept downM^ards. When both
eyes are to be operated on, we stop here on the first until we have opened
the cornea and capsule of the second.
Third Step. — If the cataract do not of itself appear in the anterior chamber,
we determine its escape by gentle and well directed pressure. The operator
applies the index finger of the left hand against the inferior part of the eye ;
with the right he places the handle of a ceratotome, or the back of Daviel's
curette, on and across the superior eyelid, so as to execute with gentle pres-
sure some slight movements to and fro over the ciliary circle, in the direction
of a line from that point towards the union of the anterior two-thirds with the
posterior inferior third of the sclerotica, passing downwards between the lens
and the vitreous humor. We soon see the lens passing out at the pupil and
presenting itself by its edge at the incision in the cornea, which it clears, or
which we cause it to clear by gentle pressure from above. It is taken away
with a curette, needle, or the point of a knife, and the operation is ordinarily
finished. If any opaque shreds of the capsule, so large as to affect the success
of the operation, can be seen, they are to be seized and extracted by the
forceps. All other fragments may be taken away in the same manner, if the
spatula or the curette be insufficient. As to those which fall into the ante-
rior chamber, at least such as are not too large, it would be better to leave
them to the solvent action of the humors than to rub the posterior surface of
OPERATIVE SURGERY. 353
the cornea so often as would be necessary to take them away by the little
spoon of Daviel. The same may be said of the diffluent lamina which so often
detaches itself from the lens while it escapes from the anterior chamber, and
remains arrested about the incision in the cornea. Whether the contact of
the instrument with the membrane of the aqueous humor inflames this lamella,
as has been asserted by Sommer, or whether it may be injurious in some oth£r
manner, certain it is, that such a proceeding is frequently followed by an
immediate and complete opacity of the anterior portion of the eye.
Remarks. — Instead of commencing the incision just at the extremity, or
a little above the transverse diameter of the eye, Wenzel prefers entering the
knife at the middle of the superior and external quarter of the cornea, making
it to pass out by the corresponding point in the inferior and internal quarter.
His reason is, that in this way the greater angle and the root of the nose run
less risk of being wounded, and that, as the flap is oblique, the eye-lids are
forced, in closing, to compress its two extremities, thereby preventing either
of them from becoming engaged in its lips. This precept is generally admitted
in France, but is far from having fixed, in the same degree, the attention of other
nations. In Germany, for example, it is so little known, that Weller, who
advises it, seems to wish to appropriate it to himself. We should not be
wrong, perhaps, to follow it where the eye is very large or projecting, because
with such a conformation the inferior palpebral border would have a strong
tendency constantly to separate the lips of the incision; but otherwise, the
advantages which have been attributed to it have been deduced, assuredly,
much more from theoretical reasoning than from practical experience. By
cutting at less than half a line from the circumference of the cornea, it is
difficult to avoid the iris ; and we should have cause to fear that the opacity
of the cicatrix would reach too near the centre of the pupil. A step which
the student finds most difficult to execute well, is tjie striking perpendicularly
on the eye. It is, however, a point of the greatest importance. In approach-
ing too near to the transverse line, the point of the knife becomes almost
always engaged between the different laminae of the cornea, gets more or less
obliquely through its thickness, and arrives at last in the anterior chamber,
but at a line and a half from its entrance ; giving, in fact, a very little open-
ing, although in appearance the wound is very large. To accomplish the
object properly, it is necessary that the surgeon should never lose sight of tlie
position of the eye, and according as this organ is more or less turned inwards
must his instrument be more or less inclined towards the temple or towards
the face. It must be recollected, at the same time, that the cornea is the
segment of a smaller sphere than the sclerotica, which occasions the perpen-
dicular at the point of puncture to be a little less inclined towards the median
line. As the knife is entering the anterior chamber, the cutting edge must
be kept as exactly downwards as possible, in order to escape the ciliary circle
and iris behind, or making a cicatrix too near the centre, if it were inclined
forwards. At the moment the point is about to pass the side next the carun-
cula lachrymalis, if it be not directed a little anteriorly, it will carry itself
towards the sclerotica and dig into the cornea. When the operator com-
mences pushing his knife, he must continue it without ceasing, making no
retrograde movement until he has completely traversed the front of the eye.
The gradual increase of the thickness and breadth of the knife permits it to
.45
S54 NEW ELEMENTS OF
fill the incision exactly, so that the aqueous humor cannot escape until the
incision is completed. But if the knife be drawn backwards in the least, it
necessarily leaves a passage for the immediate escape of this liquid. Then,
the iris floating forwards, and the anterior tunics of the eye becoming flaccid,
the incision can only be terminated with the scissors, unless it is preferred to
postpone the operation to another time. The rule requires that at least one half
of the circle of the cornea sl^ould be detached. A smaller flap would render
the escape of the chrystalline difficult, especially when it is voluminous, and
would require pressure that might be followed by the expulsion of the vitreous
humor. Ware extended it to two-thirds of this membrane, but although in
such a case gangrene of the flap, dreaded by M. Maunoir, be not much to be
feared, yet it is not necessary to go so far.
In proscribing without distinction all instruments for holding the eye,
surgeons have not thought it the less necessary to prevent all movements of
the eye whilst traversing the anterior chamber. When it turns itself obsti-
nately towards the vault of the orbit, the trefoil of Pamard is the only thing
that can render extraction practicable. If it be towards the greater angle
that it conceals itself, in case the will of the patient should be insufficient to
direct it out, we can sometimes accomplish it by the aid of the flnger, applied
over the caruncula lachrymalis. The eye might be fixed without pain, and even
without danger, between the middle and index fingers of the operator and
the assistant, if the operator were assured of the cessation of all pressure after
the knife has traversed the cornea from side to side, that is, just before the
definite completion of the flap ; but it is so easy to evacuate the eye of the
living subject, that without great practical experience it would be imprudent
to adopt this practice. Yet I see no risk in proceeding thus until the knife
reaches the greater angle. Then the operator is master of the organ. Notliing
prevents the completion of the operation, provided the blade of the instru-
ment be not displaced. Instead of the flexible probe, used by Pellier, Siege-
rist, &c., the surgeon, when the ball of the finger is insufficient to attain the
end, may use the nail of the index, or even of the little finger, in the follow-
ing manner: the extremity of the finger is placed in the greater angle, so
that its ball shall fall perpendicularly upon the internal side of the eye, and
its back forwards and towards the median line. As soon as the ceratotome
presents itself on the side towards the caruncula, its edge is placed at a right
angle upon the free edge of the nail, as if to support it; then while it is car-
ried from the external to the internal angle, the nail fixes the cornea, making
a slight effort as if to glide out towards the heel of the instrument, until the
incision is completed. By means of this manoeuvre, well understood and well
executed, a neat and regular division may be effected. The eye is neither
compressed nor dragged, and the wounding of the neighboring parts can
always be avoided. If badly executed, it would be more prejudicial than
useful ; and the projection of the superior maxillary bone, or of the brow,
makes it difficult in most subjects. Unless the nail and the knife glide firmly
upon each other, the cornea will not fail to be caught between them, whicli
would completely frustrate the aim of the contrivance. A thin slender finger,
armed with a nail somewhat long, is best adapted to this purpose. In a word,
it is necessary that the cutting edge of the knife should continue upon the
border of the nail "vvithout quitting it for an instant, without touching the
OPERATIVE SURGERY. 355
ball of the finger, and without allowing the inferior half circle of the cornea
to advance towards the root of the nose.
Notwithstanding all these precautions, the iris will sometimes present itself
under the edge of the knife. Gentle friction on the eye tiirough the upper
lid often causes it to retire, either because by this means we solicit its con-
traction, or, as appears more probable, because the pressure which is thus
exercised upon the cornea gives it its natural position, by forcing the liquid
before the caratotome to pass from the anterior to the posterior chamber ; or,
perhaps, because we straighten the fold by flattening the vitreous membrane.
At all events, we never succeed better than when we apply the naked finger
on the latter, and compress it gentl}'. The worst that can result from this, is
an unnatural perforation of the iris — a second pupil ; and this happened to
Wenzel, Roux, and Forlenze. Authors give us a number of examples. It
has happened to me several times, and I have not been able to perceive that
the restoration of sight has been rendered manifestly less complete. I think
it less dangerous than to withdraw the knife for the purpose of completing
the incision with the scissors, and that prudence permits us to neglect it
whenever it is necessary, in order to avoid it, to expose the eye to fatiguing
manoeuvres.
The elasticity of the sclerotica, perhaps also tlie action of the straight mus-
cles, is often sufficient to displace the lens, which presents itself spontane-
ously at the incision immediately on withdrawing the knife, or soon after. It
is from this fact that many practitioners have formed the idea of opening the
capsule at first, and leaving the expulsion of the cataract until after having
carried the operation to the same point on the other eye.
B. Bell, and after him Jung, for fear of breaking up the chrystalline, have
proposed to scrape the capsule, instead of incising it. It is a practice essen-
tially vicious, which only the great skill of the able oculist of Germany has
been able to spread. Pellier, Siegerist, and especially Wenzel, have thought
it would be better to open this membrane with the ceratotome whilst travers-
ing the anterior chamber, than after the completion of the incision. It was
easy for Wenzel to reach the anterior leaf of the capsule with admirable
promptitude, by inclining the point of the knife a little backwards at the
moment it passed before the iris. For less experienced operators, it would be
a mere feat of dexterity, an imprudence not without danger. It is a useless
complication of the operation to raise, as some wish, the flap of the cornea
with a spatula, whilst another instrument is directed towards the pupil. We
rarely use the cataract knife for this incision, because it is too large, and
because it wounds the iris very easily. The needle of Hey, the little myrtle-
leaf of Morenheim, the lance-shaped needle of Beer, would have more advan-
tages, would be more easy to introduce, and to use afterwards. But these
are particular instruments which can be well neglected, and replaced by the
ordinary crooked needle, or the serpette of M. Boyer, which, because of its
convex and round edge, is better suited than the others to open the incision
and tear the envelope of the chrystalline. The kystitome, either of La Faye
or of M. Bancal, enclosed in a sheath until after its arrival in the pupil, is less
likely, it must be confessed, than any of the others to wound the iris. The
principal objections to it are, that it is not indispensable, and that it can serve
no other purpose than this one.
356 NEW ELEMENTS OF
The lens escapes without difficulty by a puncture in the centre, or a semi-
lunar incision of the lower edge of the capsule, as well as by the numerous
vertical and transverse divisions which Beer was in the habit of making upon
it, because it tears what resists it ; but after it has left the capsule the shreds
of the opening approach or fall towards the visual axis, and can, by becom-
ing opaque, produce a second cataract. On the contrary, by making the
semilunar incision above, as I have advised, the tearing of the capsule must
be from above downwards, so that the resulting fragments will hang below the
pupil. Finding it sometimes very difficult to effect the destruction of the
capsule. Beer undertook to remove it entirely either with a crotchet, in the
cases of capsular cataract, or a small forceps for the encysted, or with the
lancet needle for those of the capsulo-lenticular kind. He began by sinking
the flat point of this last instrument into the centre of tlie lens, to which he
gave some slight quick movements of elevation and depression, as if to destroy
its adhesions ; he then turned it on its axis to the extent of a fourth of a circle,
in such a manner as to place one of its sides above and the other below ; then
gave it some slight transverse movements; turned it again circularly, and
after having thus completely broken up its organic attachments, withdrew it
by jirks and forced it through the pupil. Although Beer affirms that he has
many times followed this course with success, it has found, and must continue
to find, but very few advocates. In fact, who does not see that the remedy
is worse than the disease ; that we should succeed better by opening the cap-
sule largely than by detaching it en masse, and that by those repeated move-
ments, the lens will most frequently burst it and leave it behind ; an occurrence
the more probable as the posterior leaf of the capsule is not susceptible of
separation from the vitreous humor.
As to the rest, it is rare for this inner half of the chrystalline envelope to be
opaque. And this is fortunate; for unless the opacity were very limited, it
would be probably without remedy. Even then, I know not how far it
will be permitted to follow the counsel of Morenheim and Beer to isolate
the opaque spot, and attempt to extract it with a crotchet. Some have
thought, when the cataract is milky, of giving vent to the altered fluid ; others,
when it was membranous, of destroying the capsule only, in order to save the
lens in situ with its natural transparency; as if in the liquid cataract all the
lenticular apparatus was not diseased at the same time, or as if the lens could
maintain its properties in a normal state when its capsule had been opened.
Whether diseased or not, it should be taken away in all cases, if nothing else
prevents. In producing dilatation of the pupil by external means, the prepa-
rations of Belladonna render the escape of the vitreous humor very easy, and
may thus become more or less dangerous. If we reject them, the pupil
remains sometimes so contracted as to hinder the expulsion of the lens. In
order to obviate these two inconveniences, Bischoff and others have advised us
to open the cornea, then the capsule, and then turn the back of the patient to
the light, when the cataract will itself make its escape. By this means the
pupil, which is strongly contracted in the first part of the operation, dilates
itself without danger towards the conclusion. If it were expedient, we might
defer medicinal applications until after opening the eye. But we should, before
resorting to active measures, make the patient move the eye about, upwards,
inwards, and outwards ; because such movements frequently cause the escape
OPERATIVE SURGERY. 557
of the opaque body. If from any cause the vitreous humor should escape,
the eye-lids must be instantly closed and the head turned backwards. This
accident, whith entirely destroys the eye where the hyaloid membrane
escapes, is much less dangerous than was for a long time thought, in the con-
trary case. It may even be remarked, that the loss of a certain quantity of
the vitreous humor ralher increases than diminishes the chances of a success-
ful operation. The escape of the fourth, or even the half of this liquid, must
not make us despair of success. There is no evidence of its being formed
anew; but the aqueous humor, more abundantly secreted, takes its place, and
the functions of the eye are scarcely perceived to suflfer.
h. Process of Guerin and Dumont. — Witli the view of reducing the opera-
tion to its most simple expression, Guerin, and almost at the same time Du-
mont, a cruizing captain of Normandy, invented an instrument which should,
by a very ingenious mechanism, hold the eye-lids apart, fix firmly the globe of.
the eye, and complete at a single stroke the incision of the cornea." The.
first of these instruments, terminated by a sort of ring at a right angle with
the handle, concave behind and moulded exactly to fit the front of the eye,
enclosing a blade of the form of a fleam, w^iich is thrown into motion by a
spring and escaping the instant it is loosened, opens at once the half of the
circle of the cornea, either from below upwards, or the reverse. The ring
and the handle of the second are in the same line. Its blade, offering some
analogy to the pharyngotome, is made to act from the lesser towards the
greater angle of the eye moving horizontally ; different from the other, which falls
upon tlie eye like the edge of a guillotine. The instrument of Guerin, of which
perhaps the idea was given by the fleam of Van Wy, has been a long time
neglected in France, and M. Eckold is the only one to my knowledge who,
after improving it, has endeavored to introduce it in Germany. Although
more convenient and less dangerous, that of Dumont has not been better
received. If those machines of which the ancients were so prodigal, if every
species of blind agency is banished with so much care from the practice of
other operations by modern surgeons, how much more reason is there for
removing them from the eye — an organ so delicate and so easy to destroy !
The jar which is necessarily produced by touching a mechanical spring, the
fear of wounding some part which it is important to avoid, of making an opening
too large or too small, of cutting too near or too far from the sclerotica, have
particularly alarmed practitioners. It would be unjust, however, to accord
no merit to such conceptions, or to call them at once absurd as some have
done, without the means of judging of their utility. Many physicians can
attest, with M. Hedelhoffer, that Petit, of Lyons, very often and very suc-
cessfully used the instrument of Dumont. Modified by the nephew of the
inventor, it has even succeeded sixty-two times in seventy-one operations, if
all that has been recently reported to the academy be true.
C. Superior Ceratotomy. — When the inferior semi-circumference of the
cornea is opaque, or altered in any other manner, its division is sometimes
quite difficult. The incision will also be ill-disposed to cicatrize. Even
when healthy this membrane may be very small, so that it is necessary to
raise more than half to obtain a sufficient opening. In such cases Wenzel
advises the incision of the superior semicircle, and is said to have succeeded
in this way upon the duke of Bedford . Richter gives the same advice, and B. Bell
358 NEW ELEMENTS OF
formally proposed it even for ordinary cases. According to him, the escape
of the vitreous humor is less to be feared, the cicatrix of the cornea is formed
more quickly, and is less visible and less injurious to the sight than by the
ordinary process. M. Wagner published in Germany, that Mr. Alexander, of
London, has not hesitated to put the idea of Wenzel to the proof, and Mr.
Wilmot, cited by M. Eccard, asserts that Messrs. Lawrence, Green, and
Tyrell have often practised it. In France M. Dupuytren has thought proper
to try it ; but no person before M. Jaeger, successor to Beer, of Vienna, had
collected a sufficient number of facts from the living subject to found a general
method. With the superior incision, besides the advantages pointed out
by Wenzel and Bell, there is nothing to fear from the rubbing of the borders
of the lids nor the eye-lashes. M. Jaeger says the tears flow more freely, and
occasion less irritation to the incision, which also less frequently suppurates,
and procidentia of the iris must be rare. A preliminary difficulty attracted his
attention, which is the tendency of the eye to roll inwards or to turn under
the upper lid. Here he believes that he has triumphed over all obstacles, by
inventing a particular ceratotome formed of two blades, the one narrower than
the other, applied face to face in such a way as to resemble the knife of Beer
or Richter, when closed. By pressing upon a button at the side, the smaller
blade is made to glide upon the larger as in opening a sheath-handle penknife.
The patient and assistant should be placed as in. the ordinary method.
The operator holds the double ceratotome as a pen, turning the edge upwards
and pushing it across the anterior chamber parallel to its transverse axis ;
conforming in other respects to the precepts above mentioned. This done, he
gives the eye its natural position, or even inclines it a little downwards if
necessary, and fixes it with the larger blade of the knife, whilst the other
blade, set in motion by the thumb of the same hand, produces the incision
of the cornea,' by sliding from its point towards its heel.
1 Since in the space of six months M. Jaeger has practised extraction of
the cataract sixty times with success, by means of his double ceratotome, it
would be improper to assert that the instrument is absolutely bad ; a priori,
however, we can hardly see its advantages. If it is true that we can fix the
eye firmly with the stationary blade, whilst its other piece divides the supe-
rior segment of the cornea, it must on the other hand traverse the tissues
with the more difficulty. Superior ceratotomy, besides, can be very well
performed with the ordinary knife ; and M. Gr^fe, who has used it with
success seventeen times out of eighteen, and among others upon tlie Duke
of Cumberland, believes it preferable to the double ceratotome. As to the
operation itself, of all the advantages which have been accorded it, there
are very few that are real. It renders less probable the wounding of the
iris, the escape of the vitreous humor, and perhaps the separation of the
lips of the incision by the edges of the eye-lids ; but the operation in
all its steps is certainly more difficult, and less sure than in the inferior ope-
ration.*
Dressing. — After extraction the dressing and consecutive treatment differ
very little from that recommended after depression. But it is not, perhaps,
useless to present some object, not too brilliant, to see if the patient distin-
' * This is a method of exception, not of choice, applicable only to the cases indicated by
Wenzel ; supposing, at the same time, that it is not better to resort to the needle. — TV.
OPERATIVE SURGERY. 359
guishes it, before covering up the eyes. It is not to satisfy mere curiosity that
this precaution is indicated, but because such proof will give us renewed
assurance, when not perfectly satisfied that there does not remain in the eye
any opaque substance of sufficient importance to demand extraction. Re-
pose, absence of all movement of the eye, and of the superior extremity of
the body, is of absolute necessity. Although the head should be but very
slightly elevated, I see no reason which requires us to place it lower than the
feet, as done by M. Forlenze. The regimen must be more severe, longer
continued, the first dressing a little longer delayed, and the eye less early
exposed to the light than after depression.
C. Comparative Examination of the Two Methods.
Depression, which was the only method in use until the middle of the last cen-
tury, because no other was known, fell into such disuse, at least in France,
after the publication of the works of Daviel, that, in spite of the efforts of Pott
to revive it, it was scarcely practised at the commencement of the present
century. The modifications it underwent from Scarpa so far restored it to
notice, that at present it is on an eq[uality with extraction, if not above it.
Hence the question, which of these two methods is the better, already so
much debated and still undecided, presents itself to us every day. Even
if it be not incapable of decision, it must at least be confessed that the ele-
ments concerned in it are difficult to weigh. What are we to conclude from
such a method possessing a greater number of partisans of merit than such
another ? from Scarpa, Hey, Dubois, Dupuytren, Richter, and Beclard, Lis-
firanc, Lusardi, Langenbeck, having obtained greater success by depression
tlian by extraction; while with Wenzel, Ware, Richter, Beer, Demours,
Boyer, Roux, Forlenze, Pamard, it is the reverse ? When an operator, even
the most skillful and conscientious, makes choice of one method, his practice,
his predilection, always biasses him more or less, and renders him an im-
proper judge of other methods. Nor are the results announced by different
men! equally qualified, decisive arguments. The success which depression
procured to M. Dupu^i:ren does not prove that this operator w^ould have
been less successful, if in the beginning he had attached himself with the
same zeal to the improvement and propagation of extraction. To show the
fallacy of this kind of proof, suppose that twenty of the ablest surgeons of
Europe should operate only by extraction, whilst twenty others, taken at
hazard, should always have recourse to depression : because the practice of
the first shows a greater proportion of success, does it follow necessarily,
and from that alone, that extraction is preferable to depression ?
Let us see if, after having reviewed the advantages and disadvantages of
both, we arrive at any thing more satisfactory. Extraction permits us to take
away, without the possibility of its returning the obstacle to vision. It is less
painful, and rarely followed by internal inflammation ; it exposes neither the
nerves nor the vessels to being wounded, and leaves untouched all the interior
of the eye, the retina, the choroid coat, the ciliary circle, &c. But in prac-
tising it we may wound and deform the pupil, or alloAv the vitreous humor to
escape. If the incision should not heal by the first intention, it ulcerates;
soon brings on procidentia of the iris ; sometimes atrophy of the globe of the
S60
NEW ELEMENTS OF
e^e, or at least an extensive opacity of the cornea ; the sequelae of the opera-
tion are tedious ; it is rare that the ophthalmia which follows it terminates
before the fifteenth or twentieth day ; in fine, it cannot be used on all subjects,
nor at all ages.
Depression merely displaces the opaque body, and leaves it in the eye to
continue there a permanent cause of irritation, liable to reascend; it is fre-
quently followed by a secondary membranous cataract, iritis, deep-seated pain,
and general nervous symptoms. The needle traverses delicate tissues, wounds
of necessity the choroid coat, the retina, the vitreous humor, and sometimes
also the iris and the ciliary body. But on the other hand it cannot give issue
to the vitreous humor, does not expose the cornea to opacity or ulceration,
the iris to procidentia or excision, nor the eye to immediate destruction. The
day after the operation the puncture is closed, and the sclerotica, which most
frequently is scarcely inflamed at all, resumes, in about eight or ten days, its
natural aspect ; in fine, if necessary, it can be performed in all cases, and
repeated once or oftener on the same organ without running any great risk
of injury to the patient.
According to this enumeration, it would at the first glance seem that de-
pression must be superior to extraction. But a profound examination does
not permit us to draw a conclusion so clear and positive. The puncture of
the sclerotica, choroid, retina, and vitreous body, does not produce much more
pain than the incision of the cornea; at least, when performed as I have indi-
cated. The wounding of the nerves, vessels, and ciliary body, is easily pre-
vented, and generally unimportant. When the capsule of the lens is properly
torn, we cannot see why secondary cataract should be more common after
depression than after extraction. If the lens be well engaged in the vitreous
humor, it is difficult for it either to rise again or to hurt the retina. With
address we can easily preserve the iris, which the needle never wounds so
severely as the ceratotome. But it is erroneous to say that this method is
more simple and easy than the other. It is not so easy as may be imagined,
to pass an instrument between the uvea and the cataract; to engage it between
the lens and its envelope ; to make a suitable opening in the capsule to prevent
the opaque body from turning either upwards or downwards, if the needle be
pressed ever so little in either direction more than in the other, or if the lens
should have contracted adhesions to any of the neighboring parts ; in fine, it
is often only after repeated attempts that we can succeed in getting it down,
and fixing it in the bottom of the eye. The greatest address is then necessary to
practise depression with every chance of success. If it be generally preferred
by inexperienced men, it is much less because of its apparent simplicity than
because it does not expose their deficiency so readily as extraction. Again,
the irritation which it produces augments the secretion of the humors, pro-
ducing a feeling of distention in the eye which does not take place after the
other operation. Acute or chronic iritis, contracting or entirely obliterating
the pupil, may also often be a consequence of this process. The laceration
of the vitreous body, although without immediate danger, may not be always
exempt from inconvenience. The lens, which does indeed sometimes disap-
pear by absorption or dissolution, more frequently retains its form and volume
for some years or for life ; whatever the moderns may say of it, after Pott,
Scarpa, and Dablin, who in 1722 proved its absorption, and concluded that it
OPERATIVE J5URGERY. S6l
constantly disappears after depression. Beer has seen it rise again at the end
of twenty-six years. Of twelve patients operated on by depression, whose
eyes I have had an opportunity of examining in the hospital after death, one,
two, two and a half, and four years after the operation, it had scarcely dimi-
nished one fifth in the only subject in which there was any sensible alteration.
In others it had formed, through the intervention of some laminae of the hya-
loid membrane, adhesions to the retina and choroid coat, itself presenting a
sort of knob or cicatrix about three lines long. M. Campaignac, who has made
many researches, especiully on this point of practice, also says, after numerous
observations, that the lens is far from disappearing so quickly or so constantly
as is generally believed after depression. This is an inconvenience, it must
be confessed ; and an inconvenience that no argument can destroy, and which
will always render the operation by depression less complete than that by
extraction. Keratonyxis, which Dr. Wedermeyer rejected after having tried
it fifty-three times, will succeed no better; and, whatever M. Schindler, who
defends it, may say, it would be a poor way of securing supporters, to pene-
trate as he does at the centre of the cornea, instead of the lowest point.
Escaping, or left in the anterior chamber, either whole or in small fragments,
the lens is far from dissolving as promptly as some ai«Jiors pretend. Observ-
ations made by M. Plichon, at La Salpetriere, prove that it often act% as a
foreign body, and if not soon removed exposes the eye to serious dangers.
Another defect, still more important, is the following : the iris may remain
movable, and the pupil clear, and the whole organ bear the appearance of per-
fect integrity, yet the vision may b^. totally destroyed. I have seen, at the
central bureau, four persons who had been operated upon at Paris, blind from
this cause. A man, aged sixty-two years, on whom I operated in 1829 at the
hospital of St. Antoine, has recently asked my advice. At first sight any one
would affirm that his vision was perfectly good. The pupil is of a beautiful
black ; round, regular, movable ; neither dilated nor contracted too much, and
yet his blindness is complete. What has so often imposed upon the partisans
of depression is, that the patients seem so often to recover their sight after a
certain time, and keep it, in fact, during a month or two, but afterwards find
it gradually growing weaker, until in less than a year it is entirely gone. If
the operation, repeated seven times in one case, six times in another, and thir-
teen times on each eye in a third, have enabled Dr. Hey to cure his patients,
it does not make it the less true that these secondary attempts are most fre-
quently unsuccessful. The truth is, however, that the consequences are com-
monly trifling. After depression there almost always remain, or are formed,
some particles, more or less opaque, before the vitreous humor. Experience
proves that after extraction this accident is much more rare.
As to extraction, it is evident that the section of the cornea is much more
delicate than the perforation of the sclerotica ; that in spite of every precau-
tion the vitreous humor may escape, the iris be extensively wounded by the
knife, or ruptured or torn by the lens ; yet if the operation is well done and
the patient in good condition, two accidents only, the escape of the vitreous
humor and the consecutive opacity of the cornea, can render it dangerous :
while, all other things being equal, it gives a result immediate and definitive,
and more satisfactory than that of depression. But it must be said that the
escape of the lens endangers two other accidents. Although largely dilated
46
30g NEW ELEMENTS OF
by the belladonna, the pupil almost always contracts enough to oppose some
resistance to tlie opaque body, which then tends to tear up the iris from below
80 as to escape, if the pressure on the eye be not conducted with extreme
caution. This pressure, brought suddenly upon the, cornea bj an unexpected
movement of the patient, may, if it occur at the moment the edge of the cata-
ract presents itself at the flap, push it up over the vitreous humor ; leaving
us in doubt whether it has really escaped or is yet in the eye, as once hap-
pened to me. Procidentia of the iris, which is more frequently a consequence
of the operation in old persons, because of the slowness of the cornea to cica-
trize in them, is treated by mechanical means or belladonna if there be no
adhesion, but with the nitrate of silver if there be ; and is not more difficult
to cure in these than in other circumstances. When an operator desires to
leave no opaque particle in the eye, there is no objection to throwing in one or
two injections of lukewarm water through the incision with AnePs little
syringe. Perhaps it would be even advantageous to imitate M. Forlenze, and
adopt this method generally. In a word, if the dangers of extraction are more
serious and apparent, those of depression are more numerous and real. Ope-
rators of equal skill avoid more easily those of the first than those of the
second ; and if the employment of the needle fails less frequently to procure
gome benefit to the patient, the method of Davicl furnishes in compensation
a greater amount of complete cures. I conclude, then, that when circum-
stances occur which render it indifferent which of the two may be used,
extraction should be preferred ; but in other cases sometimes one may be
adopted, and sometimes the other.
Depression appears preferable, for example, upon infants and intractable
subjects, whentlie eyes are small and sunken; when the cornea presents spots
of opacity, is small or flattened ; when the eye-lids or the conjunctiva has been
a long time diseased ; when there is cause to apprehend active inflammation
of the appendages of the eye ; when the cataract is completely fluid ; when
the pupil is contracted, or the iris adheres to the cornea ; when the eye is very
prominent or very irritable. Extraction, on the contrary, offers greater advan-
tages with old persons, and even adults, if the anterior chamber be large; the
lens very soft or very hard ; the cataract membraVious or adherent ; the eye per-
fectly healthy, not very sensitive, and susceptible of being pierced without
difficulty. I should add, in concluding these remarks, that any surgeon
would sin against humanity if he should practise the operation for the cataract
before he had exercised himself at first a long time upon the dead body, an(][
afterwards upon living animals. Yet it must be stated that this kind of expe-
riments are far from giving an accurate idea of what really exists in the living
subject ; and that extraction alone can be simulated in a way at all sa^tis-
factory.
Surgeons have long felt the want ^f a means of producing artificial cata-
ract, to give the means of preparatory practice upon animals and dead sub-
jects, and leave the eye at the same time all the mobility which renders it so
difficult to be fixed at the moment of operation upon the living. Troja, in
Italy, and M. Bretonneau, in France, have made some attempts to render the
lens opaque by the aid of acids. M. Leroy thought it could be better accom-
plished by means of electricity ; but no person before M. Neuner, of Darm-
stft-iit, made it a particular object of study. The liquid he used with greatest
OPERATIVE SURGERV. S6S
success was a solution of six grains of corrosive sublimate in one gros of pure
alcohol. A small glass syringe garnished with platina, terminated by a very
fine pipe, and traversed by an extremely fine stylet that passes through both
extremities, is used for the purpose of introducing to the lens from behind a
few drops of this solution, which soon causes that body to change its color.
Among the machines invented to represent on the eyes of the dead subject
the principal difficulties met witl\ on the living, the ophthalmophantome of M.
Sachs is certainly the most ingenious : composed of a stand, a mask, and a
porte-oeuil, of w^hich I cannot here give a description. It appears to me too
complicated ever to come into general use.
After one of the chief refractive agents of the eye has been either removed
or displaced, I need not say that almost every individual operated on for cata-
ract should wear such convex glasses as are used by near sighted persons.
With children, those who have been blind from birth, and all subjects, in fine,
who for the first time are beginning the cultivation of their sight, it is well to
add to the precautions generally used a very simple resource employed with
success by M. Dupuytren, which consists in fixing the hands behind the back,
so that being deprived of these assistants they are forced to make greater exer-
tions with their eyes in directing themselves towards external objects.
§ 4. Artificial PupiL
Two very different states may require the establishment of an artificial
pupil : opacity in the cornea, or the contraction or obliteration of the natural
pupil. In the first case, whether the obstacle to vision may have been the result
of simple ophthalmia, ulcer, wound, or any other lesion, is of little im-
portance. Provided the internal parts of the eye be unaffected, and there
remains a transparent portion of the cornea, the formation of an artificial pupil
may be tried. In the second, whatever be the cause or degree of the disease ;
whether it be simple or complicated with adhesions, the operation is practica-
ble if the retina have not lost its faculty of perceiving luminous rays, and the
anterior chamber preserves its transparency. If this last condition be want-
ing, it is useless to make a new pupil for the transmission of light, for the
impression will not be felt. Acute and chronic inflammations of the internal
tunics, as well as every kind of alteration, the course of which has not been
definitively arrested, are contra-indications, which, although less absolute, are
yet sufficient, with some exceptions, to arrest a circumspect surgeon. Almost
all authors advise not to attempt it when there is only one eye affected, or
even otherwise when the patient is able to conduct himself without a guide.
As the operation is itself sometimes followed by accidents capable of deeply
affecting the vision, it appears but little conformable to the laws of humanity
to expose the sufferer to the loss of the little that yet remains, when the chances
of amelioration are so precarious.
A. Methods of Operating.
Every process invented for forming a new pupil may be reduced to three
methods. The first, iridiotomy or Qoretomia, consists in incising the iris ; the
S64 NEW ELEMENTS OF
second, iridectomia or corectomia^ in excising a piece of this membrane ; and
the third, iridodialysis or coredialysis, in detaching its circumference at some
point.
1. Coretomia or the Method hy Incision. — No one before Cheselden had
spoken of tliis process. Since his time it has attracted the attention of Wool-
house, Mauchart, Sharp, Sprasgel, Meiners, and Rathleau, who have proposed
it in case of a persistence of the pupillary membrane; of Odhelius, Guerin,
Janin, Wenzel, and of Messrs. Maunoir, Adams, &c., who have subjected it
to several modifications. The patient, operator, and assistants must be placed
ajs in the operation for cataract.
a. Process of Cheselden. — With a small knife in the form of a scalpel,
cutting on one side only, Cheselden penetrated through the sclerotica, as in
couching, as far as the uvea, and passed the point of the instrument into the
anterior chamber. Then directing it inwards and backwards according to
some, or according to others from the internal angle to the external, and
from behind forwards, he completed a transverse incision from two to three
lines long in the centre of tlie iris. A pupil of an elliptical form, similar to
that of some quadrupeds, was the result of this delicate operation, which suc-
ceeded well and forcibly attracted the attention of the learned.
b. Process of Sharp.— In practising coretomia Sharp claims to have done
nothing more than to imitate Cheselden. A little scalpel slightly convex on
the back, of which he gives a figure, is at first carried horizontally, the edge
turned backwards, into the posterior chamber between the circle and the root
of the ciliary processes. It is then enough to incline the point more or less
anteriorly, and give it a slight push to penetrate into the anterior chamber. It
remains to cut the iris either on a level with or below, or which is better, above
the natural pupil. The opening produced by this operation, which continues
for some time, never fails to contract, and at last even to become entirely
closed. Even Sharp appeared to have little confidence in Cheselden's method.
Mauchart deserves to be mentioned here, only because he was the first to sug-
gest the idea of passing the instrument through the cornea or anterior chamber
in forming the pupil. He objects, besides, to giving the artificial opening too
great an extent, because, as he remarks, this kind of a pupil can neither dilate
nor contract spontaneously like the natural one. Henkel also preferred to
penetrate through the anterior chamber. Huermann, who is of the same
opinion, advises us to use an ordinary lancet instead of needles or the knife
of Cheselden, to cut the iris and cornea.
c. Process of Odhelius. — After having pierced the cornea as for the extrac-
tion of cataract, Odhelius cut the iris from the centre to the circumference
in a subject whose cornea was opaque opposite the pupil, which was also
contracted. By this means he obtained a triangular opening — the base
being the remains of the primitive pupil, and thus completely restored the
sight.
d. Process of Janin. — Having frequently tried Cheselden's method without
success, Janin thought to succeed better by giving a vertical direction to the
incision. The transverse one soon and almost necessarily closes itself, he
said, because the radiating fibres of the membrane are only separated, whilst
they are really cut by a perpendicular incision made a little to the inside
of the natural pupil. It was an accident that led him to this modificatioo.
OPERATIVE SURGERY. 365
It happened to him as to many others, to cut the iris in performing the
operation for extraction ; making thus against his will an artificial pupil at
the side or rather below the natural one. Seeing that this opening made by
chance did not close, whilst those which he had made by design were always
obliterated, he endeavored to profit by his mishap, and set himself to mature
the process which chance had pointed out. Instead of scissors, Kortum
advises us to cut the iris vertidlally with the same ceratotome which is used in
dividing the cornea. But in spite of the experiments of Weissemborn and the
observations of Pellier, which tend to confirm its advantages, the method of
Janin was soon abandoned by practitioners. It was not long before it was
found that a pupil so formed does not remain much longer than that formed
by any other method. Like Pellier, Huermann, and Henkel, Janin penetrated
through the anterior chamber.
e. Process of Guerin, — To obtain the advantages of both, Guerin proposed
to combine the methods of Cheselden and Janin ; that is, to make a crucial
incision instead of one simply vertical or transverse. But on the one hand
the operation is then more difficult, and on the other it is not rare to see the
four flaps approximate so as to prevent the light from reaching the bottom of
the eye ; so that the practice has not much to recommend it. When vision is
prevented by leucoma, Pellier enlarged the natural pupil, instead of cutting
out a new one. For this purpose he opened the cornea as if for extraction,
passed a small grooved probe into the posterior chamber of the eye, which
served to direct a pair of small scissors, and then divided the iris outwards,
inwards, or upwards, from the pupil to the ciliary ligament.
/. Process of Maunoir. — Although the result of the individual researches of
its author, the method invented by Maunoir seems to be but an improvement
of that of Pellier. This surgeon, by means of a ceratotome or lancet, made an
opening from two to three lines long in the inferior and exterior part of the
cornea, through which he introduced a pair of very small scissors bent at an
angle near the handles, one of the blades of which terminated in a head ;
opens them in the anterior chamber, and passes one blade through the iris
into the posterior chamber, so that the other with the button remains behind
the cornea ; thus seizing the membrane, he incises it first inwards, then out-
wards and upwards so as to form a triangular flap, the adherent base of
which is towards the circumference and the free summit towards the centre
of the eye. The scissors -needle, invented by M. Montain for the purpose of
avoiding the previous division of the cornea, although ingenious, offers no
improvement sufficiently useful to merit the preference claimed for them by
the inventor. By the double incision the circular fibres which M. Maunoir
admits in the iris are twice cut, while its radiating fibres remain untouched ;
these by their contraction tend to dilate the new pupil, the reverse of which
takes place in Cheselden's operation. The ideas of the surgeon of Geneva
have received the sanction of the celebrated Scarpa, who in defence of them
renounced his own method. This method has also found partisans in Ger-
many ; but in France and England it is generally neglected. Above all, it is
evident that if it be desirable to attempt coretomia in this manner — of which
M. Carron declares himself the ardertt defender in an unpublished work
which I have before me — it may be advantageously modified by using, as I
have several times done, an ordinary ceratotome for cutting the triangular
166
KKW ELEMENTS Of
flap of the iris ; doing by design what is so often done by accident in the
operation for the extraction of the cataract : what Wenzel appears to have
advised, and what Odhelius performed.
g. Process of Mr, Mams. — Lately Sir William Adams has revived the
method of Cheselden, with this difference, that instead of a straight knife
like Sharp's, he employs a small scalpel, convex on its edge ; that he breaks
up the lens if it be opaque, and tries before quitting the eye to engage some of
the pieces in the transverse incision of the iris, to pnevent its closing. M. Roux
used this method several times whilst I was his assistant, and in every case
the new pupil finally disappeared. Besides, it appears not to have received
much confidence in the author's own country ; for it scarcely appears to have
been tried by other surgeons. I have not myself been more happy in two
attempts which I have made.
Coretomy was still further modified by Jurine, Langenbeck, Weller,
Faure, Wardrop, who carried a needle into the posterior chamber; penetrated
the iris from behind into the anterior chamber ; then passing again in the oppo-
site direction through this membrane in the internal angle of the eye, returned
the point of the instrument into the posterior chamber ; then united the two
little wounds by means of one of the edges of the instrument rather than the
point, detaching one of the extremities of the flap which they had circum-
scribed. But it has found numerous antagonists recently amcmg the oculists
of Germany. They object to it, that in passing the needle through the iris,
either from the anterior or the posterior chamber, a lesion of some of the
apparatus of the lens is almost inevitable, becoming one of the most ordinary
causes of cataract and rarely followed by permanent success; that it is
difficult of application when there is an opacity of the cornea, or if there
exist adhesions or even simple synechia of the iris. Although all those
objections have some foundation, they are not of a nature to make us
reject the operation entirely. I have thought too of modifying it still
farther.
h. Process of the Author. — I use a knife a little longer and narrower than
Wenzel 's, cutting on both edges as far as four lines from the point, and dull
or rounding from thence on the back to the handle; an instrument of which
the lancet called the serpenfs tongue will give a very good idea. Held as a
pen, it is pushed like any other ceratotome through the cornea from the tem-
poral side of the orbit a little obliquely backwards. When it has reached the
anterior chamber, the point is to be passed with great care through the iris
into the posterior chamber, so that it may be easily returned through the
same membrane at another point into the anterior chamber, leaving an inter-
val of two or three lines. Then continuing to push it on until it pierces
the cornea a second time, it is easy to divide the kind of bridge that covers
its anterior face, and only to detach completely one extremity of the flap,
after having reduced the other to as small a pedicle as may be desired. A
division can thus be obtained equivalent to a loss of substance. The small
flap that is made will not fail to contract upon itself, and eventually must be lost
in the aqueous humor. When the manoeuvre is well executed, it is even
possible in most cases to excise the piece entirely. In fact, if the instrument
acts equally upon the adherent sides of the flap at the moment the section
of cue side is performed, it is sufficient to advance the ceratotome a little, and
OPERATIVE SURGERY. S67
incliae its edge towards the cornea in order to detacn the other, and convert
coretomy into corectomy.
2. Coredialysis. — To Scarpa is due the introduction of this method. Manj
authors, however, had spoken of it before him. Sharp, for example, remarks
in speaking of coretomy, that when pressed bj the instrument the iris is
often detached from its insertion instead of divided. In a patient treated
for cataract by Wenzel, the lens escaped through such an accidental opening.
The natural pupil afterwards almost entirely disappeared, but the patient
continued to see through the abnormal opening. If Assalini may be believed,
Buzzi, of Milan, who practised coredialysis as early as 1788, passed the
needle through the posterior chamber into the iris at a line from the oblite-
rated pupil, and by well managed tractions detached this membrane from the
ciliary circle. A. Schmidt, who published a good memoir on the subject in
1803, is said to have used it in 1802, and to have conceived the idea of it in 1792.
a. Process of Scarpa. — When his needle has reached the interior of the eye,
the same as for depression, Scarpa turns the concavity forwards, passes it
behind the internal and superior part of the uvea, and presses the point
through the iris into the anterior chamber ; then using it as a crotchet, with a
kind of see-saw motion, downwards, forwards, and outwards, until it detaches
the greater circumference of this membrane for about two or three lines, so as
to produce an opening a little larger than the natural pupil.
b. Process of T, Couleon. — Tache Couleon among the earliest, Flajani,
Himley, Beer especially, and Buchorn, advise that the needle, either straight
or curved in any manner, be passed through the cornea, and not the sclerotica,
as done by Scarpa. According to them, it is as possible in this manner to
make the new pupil on the outside as on the inside, besides giving the operator
a better opportunity of seeing what he does, and making the puncture of the
eye less dangerous.
c. Process of Assalini. — After having made an incision at the external angle
of the cornea, Assalini introduced into the anterior chamber a fine curved
forceps, with which he seized the iris at a little distance from its ciliary bor-
der and detached it, as in Scarpa's method. This forceps appeared useless to
Bonzel, who replaced them by a very small crotchet used in the same manner.
Dzondi employs a kind of forceps, one of the branches of which is grooved on
the internal face to receive the other when the instrument is closed. He
asserts that there is no risk of tearing the iris with this instrument, and that
it is easier to effect the detachment with it than with any other.
The strongest and best founded objection to coredialysis is, that the
detached border of the iris resumes after a little while its natural position,
and that after a certain time the new pupil is always closed.
d. Process of M, Langenbeck. — To obviate this inconvenience, M. Langen-
beck, after seizing the iris by means of a little crotchet protected by a sheath,
and drawing it gently towards him, engages it in the wound of the cornea,
which should be very small, and fixes it there as if to produce myocephalon,
and then disengages his instrument with the utmost caution. The adhesions
which soon form in this kind of hernia prevent the pupil thus made from
contracting, and give the operation every necessary security.
e. Reisinger, who professes the same idea, objects to the sheathed crotchet
of M. Langenbeck, and uses a simple ocular forceps, the point of which is
368 NEW ELEMENTS OF
curved in a hook on one side. This forceps is introduced flat and closed
into the anterior chamber ; then, with the concavity turned awaj, it is opened
one or two lines, and closed again after having been sunk into the iris. This
membrane, being thus pinched or grappled, is detached and drawn out, so as
to produce an artificial procidentia. The coreoncion, so much boasted of bj
M. Grasfe, is employed in the same manner as the crotchet of M. Langenbeck,
and differs little from it otherwise than by a small ceratotome which it has at
one of its extremities.
/. Process of M. Lusardi. — Very recently M. Lusardi has proposed to
reduce coredialysis to its greatest simplicity, by inventing a crotchet-needle
which is sufficient alone to perform the whole operation. This instrument
when closed has the form of Scarpa's needle, or rather of a very small hook-
knife. Its two shanks are so disposed, that by drawing the shortest a little
back — that which corresponds to the concavity — there results an opening which
transforms it into a real forceps. It is introduced through the cornea as if for
ceratonyxis, then passed by the anterior chamber, if that be free ; if not, by
the posterior chamber, after having penetrated the iris at the ciliary circle.
Arrived there, the surgeon applies the back against the greater circumference
of the ocular diaphragm, which he endeavors to detach by swaying the instru-
ment; then opens the needle and allows it to spring, and the membrane is
caugiit. There is then nothing to do but to draw it towards the opening in
the cornea, with such precautions as are necessary to produce a new pupil of
proper dimensions. With this instrument, which had already been described
in Italy by Donegana and Baratta, M. Lusardi thinks there is no risk of
injuring the capsule of the lens — which is not proved — and that he can
establish an artificial pupil upon any point of the ciliary circumference, which
is more correct; but the ordinary needle offers nearly the same resources; and
the most important advantage whicn I can see in this serpette is, that it
enables us to excise a part of the iris ; to have recourse to corectomia at once,
if there be any cause to fear that coredialysis may be insufficient. I shall not
speak here of the method of Assalini, who, to remove the new pupil as far as
possible from the lens, advises us to destroy a part of the circle and of the
ciliary processes at the same time that we detach the great circle of the iris ;
it is too directly contrary to the end proposed for any surgeon ever to have
recourse to it.
g. The Method of Donegana does not deserve the same proscription.
Seeing that after coredialysis, according to Scarpa's method, the new pupil
almost always ultimately closes, this oculist has proposed, to prevent that
inconvenience, to unite the method by incision to that by detachment. Con-
sequently he incises the iris parallel to its radiating fibres from the greater
towards the smaller circumference for about two lines, after having detached
it from the sclerotica. For this purpose we may penetrate through either
chamber, and use an ordinary needle, or an instrument with a blade a little
thinner, almost straight, and very sharp. Unfortunately it is not as easy,
however, as one would suppose, to cut the iris after detaching it in the interior
of the eye. It folds under the knife, and tears or separates from the neigh-
boring parts much easier than it di\ ides. However, this is an improvement
that may be of some assistance, and which it would be advantageous to attempt
when we wish to practise this operation according to Scarpa's principles.
OPERATIVE SURGEKY. 369
3. Coredomia.—a. rre»ze/ appears to have been the inventor of eorectomia.
Yet it cannot be denied that Guerin had practised it before him, who, as re-
marked b}^ Sprengel, sometimes excised the point of the flap of his crucial
incision. Sabatier, who adopted the practice of Wenzel, has given us the
most satisfactory idea of it. The first steps are the same as for extraction.
Whilst crossing the eye the knife is made to form a flap in the iris similar to
that of the cornea. A pair of small scissors introduced into the anterior
chamber is then used to separate it at the base, seizing it at the same time at
the point with a pair of small forceps, if necessary. An opening is thus obtained
by removal of substance that offers every chance of success.
b. Process ofM. Demours. — M. Demours thought proper to pursue a method
somewhat different in case of the existence of leucoma. He made an
incision into the anterior chamber, which comprehended at the same time both
cornea and iris ; then with two cuts of a pair of scissors he circumscribed
and took away a flap from the latter about as large as a leaf of sorrel. The
difference between these two methods is but trifling. If the first offer some
advantages by permitting us to stop at coretomy when that is deemed sufticient,
the second exposes less to the danger of evacuating the eye. To one or the
other may be ascribed the principal processes extolled by the oculists of the
present day.
c. Process of T. Couleon and Dr. Gibson. — Like Wenzel Dr. Gibson
opens the cornea at first as largely as if for extraction of a cataract, but
does not touch the iris. He then forces this membrane through the incision
by means of gentle pressure upon the globe of the eye, and with a pair of
scissors excises a disc of suitable dimensions. M. Forlenze does not hesitate
to open the cornea for two-thirds of its circumference, so as to seize the iris
with a forceps or a crotchet, and remove a flap, like M. Demours. In a thesis
defended in 1803, M. Morault ascribes a similar method to T. Couleon.
d. Beer asserts that an opening of two lines in length in the cornea is suf-
ficient for the iris. to become spontaneously engaged, and that then we may
excise the part that attempts to escape. If this do not happen, he draws the
membrane tow^ards him by means of a hook.
e. Process of M. Walther. — For the purpose no doubt of reconciling the
principles of Gibson with those of Beer, M. Walther opens the cornea for
about three lines, draws the iris outwards with a crotchet, and excises a flap of
suitable size with a pair of small scissors. By an opening nearly similar,
M. Lallemand, of Montpelier, has been able to seize the membrane with
the small crotchet forceps, draw it towards him, and excise a considerable
piece, thus forming an elliptical pupil similar to that of the cat, vertical,
and two lines broad and six long. The success was so complete, says the
author, that the patient is able to follow the army of Spain as overseer of an
infirmary.
The forceps -needle of Wagner and Dzondi, the raphiankistron of Emden,
the irianklstron of Schlagintweit, and the method of Himley, do not, differ
enough from those above mentioned to justify me in detaining the reader with
them. I will say the same of the method of Autenrieth, which consists in
destroying a portion of the sclerotica, of*the ciliary processes, and cirule ; in
taking away, in short, a disc from the oculai- shell, behind the cornea, taking
the simple precaution to close the opening with the conjunctiva, which is to
47
370 NEW ELEMENTS OF
be previously separated. The best that can be done for such an idea is
not to speak of it. ^
/. Process of Dr. Fhysick. — After having' cut tlie cornea and iris in con-
formity with the precepts of Wenzel, Dr. Physick introduces into the anterior
chamber forceps terminated by plates, somewhat similar to our chin^ney-
pincers. The inner face of these plates presents at their circumference a
cutting edge, forming a pair of scissors of a peculiar kind, with which it is
easy to seize and remove a flap of the iris after a stroke of the ceratotome.
B. Relative Value of the Various Methods .
These various methods show at least the ceaseless efforts of practitioners
to improve one of the most delicate operations in ocular surgery. Unhappily
there are obstacles and difficulties often met with here which the greatest ad-
dress, the most consummate ingenuity cannot surmount. Considered in an
/ abstract point of view, there is no doubt that corectomiais superior to the other
two methods. Yet in practice, as the instrument used must cross the anterior
chamber, it is almost impossible to have recourse to it when the iris adheres
to the cornea, or when the latter membrane is opaque for a considerable extent.
Coretomia presents nearly the same inconveniences,without all its advantages ;
and besides, experience proves that the opening it produces rarely persists
more than a few weeks. To coredialysis then must be accorded the prefer-
ence. It is the same in case of adherent membranous cataract, or an opacity
of any kind before or behind the iris which cannot be destroyed ; observing
that we are forced to carry the pupil towards the circumference of the iris.
Only coretomia and coredialysis permit us to operate by scltroticonyxis. Yet
as they can be as well performed by keratonyxis, we should prefer the former
only in cases of very distinct synechia anterior, because it renders a lesion of
the lens almost inevitable. Should any one desire to perform coretomia
without trying the process which I have contrived, I would recommend to
him that of M. Maunoir, or that of Wenzel, which is still better. For co-
rectomia we may use indifferently the method of Demours, Forlenze, Gibson,
Beer, or Walther; although the best of all in my opinion would be that of
Physick (as I have modified it), if it were possible to get an instrument small
enough and finely finished, which I have not yet been able to do. When it
has been decided to perform coredialysis, the simple crotchet of Bonzel will
answer all the purposes of the more complicated instruments of Beer, Rei-
singer, &c. ; but I doubt whether it be as easy as it seems to be admitted by
these authors, to fix in the opening of the cornea the portion of the iris which has
been with more or less difficulty drawn out. If the accident which we hope to
remedy by forming an artificial pupil be manifestly the consequence of an ope-
ration for cataract, there is then much less inconvenience than in other cases in
passing the instrument by the posterior chamber. But then at the same time
the eye is too much altered to permit very great hopes of success. It is evidently
unnecessary to open the anterior chamber as largely as advised by Wenzel,
Forlenze, and Gibson. If the lens and its capsule be healthy, it is otherwise.
Yet if there be any suspicion of opacity in these parts, it is better to extract
them.. Perhaps we should even make it a rule to extract them whether opacity
had coipmenced or not. By this means we would escape the unpleasant sight
OPERATIVE SURGERY. 371
of a consecutive cataract making its appearance to destroy the chances of suc-
cess of the primary operation, as happened to me in a man aged thirty years.
With this view the opening of the cornea could not be too large, since we
operate for cataract and artificial pupil at the same time. When there are
opaque spots on the eye, and when keratonyxis cannot be performed, the case
becomes very embarrassing. If the incision be upon the healthy front of the
cornea, the cicatrix resulting from it and the inflammation which follows it, too
often destroy the little transparency that the primary disease had left. The
leucomatose portion, on the contrary, we have cause to fear will suppurate
and cause the loss of the eye. Yet many practitioners, and among them
Fause and Lusardi, have remarked that the section of a cornea thus opaque
is not so dangerous as it is generally thought to be ; and they go even so
far as to say it agglutinates more rapidly than when it is not thus diseased.
This is easy to be conceived ; for such tissues being less sensible, less excit-
able, nearer the state of vegetative life, must inflame more moderately than if
in a perfectly normal state. If then the cornea be opaque to a great extent,
we must husband carefully that part which yet remains good, and penetrate
through the altered portion. In the opposite case, when the transparency is
affected only in a small and very circumscribed spot, it is better to cut the
sound tissue. To be prepared for every exigency, every variety of form
under which the disease may present itself, it is well to become familiarized
with the various methods I have detailed, each of which may at times offer
peculiar advantaj2:es. I will add, however, that the method by excision is the
only one which offei's ultimately any real chances of success. All the methods
by incision, either simple or complicated, as well as that by detachment, are
decidedly bad, and shoujd be adopted only by way of exception. I have per-
formed this operation according to the precepts of Scarpa, W^enzel, and
Maunoir ; and although the artificial pupil has remained large enough for some
time, it has always ultimately reduced itself to almost nothing. I have
recently practised upon a young girl the method of Odhelius, and although the
opening appeared at first very large, it has already begun to contract. These
facts and the wounds of this same membrane during the operation for cataract,
have satisfied me that the various methods based upon the supposed muscular
nature of the iris are built upon a false foundation. Instead of retracting
itself towards the root, the flap of the iris which I made in 1829, at St.
Antoine, on a man sixty years of age, on the contrary, approximated little by
little towards the point from which it had been separated. The same thing
happened to me in 1831, at La Pitie.
After the operation the patient must be subjected to the same regimen and
the same precautions as if he had been treated for cataract. Yet the con-
sequences are rarely as serious. After keratonyxis and even scleroticonyxis,
they are often reduced to the slightest inflammatory symptoms. If the
patient has not completely or for a long time lost the habit of perceiving
light, we can frequently dispense with confinement to bed, and be content
with making him wear a bandage of black taffeta for some days. The lady
operated on by Wardrop, returned in a carriage immediately after without
any bad result. An ungovernable subject, upon whom I could impose no
rules of conduct, got up the same night of the operation, would not submit to
any retrenchment in his aliment or change in his habits after the expiration
S72 NEW ELEMENTS OF
of the next day, and this without being affected with the least inflammation.
Of seven others upon whom I operated, none suffered from inflammatory
symptoms. But when we have performed keratotomy ; when we have opened
the cornea extensively, like Wenzel, &c.; when we have thought it neces-
sary to extract the lens or its appendages ; and when tlie natural pupil has
been completely closed for a long time, it would be very imprudent not to
enforce exactly the same regimen as after an operation for cataract. In all
these cases the most intense ophthalmia may be easily induced.
§ 5. — Puncture — Incision.
Puncture of the eye was formerly employed in onyx, or effusion of pus
between the lamellae of the cornea ; in hypopyon, or abscess of the anterior
chamber ; empyesis, or abscess of the posterior chamber ; hydrophthalmia ;
buphthalmia : and in all cases, in fine, where the eye was the seat of an exces-
sive accumulation either of its ownnatural humors, or of any abnormal liquid.
1. Onyx. — When the small purulent spots which sometimes form in the
thickness of the cornea have been vainly combated by antiphlogistics, emol-
lients, discutients, &c., nothing appears more rational than to open them.
The operation is, however, so simple, that it is scarcely worth describing.
The surgeon, depressing the lower lid whilst the assistant elevates the other,
seizes, with the right hand for the left eye and the left hand for the right eye,
an ordinary lancet, bare or enveloped with a ribbon nearly to the point, and
divides the layers of the cornea which separate the onyx from the exterior
with all necessary caution, repeating the puncture as often as the separate
abscesses in the front of the eye may require it. A cataract needle will do
as well as a lancet, and any pointed cutting instrument will serve. Unless
the transparency of the cornea be utterly destroyed, the instrument should
be carried as far from the centre of the organ as the disease will admit, and
penetrate rather obliquely than by a perpendicular incision. Some surgeons
disapprove of either puncture or incision in these cases. It aggravates, they
say, or reproduces the inflammation, leaves indelible cicatrices, and may
produce other serious injuries to the eye. Besides, the matter forming the onyx,
almost always adherent to the lamellae, is rarely so fluid that it will escape
from a simple incision. Finally, this pus disappears of itself when the
ophthalmia which produced it is entirely removed. Although adopting some
of these reasons, I think the operation useful when the pus is gathered into a
true sac, in a fluid or concrete mass large enough to take away all hope of
its disappearance without surgical aid. The facts which science possesses,
and the late labors of M. Gierl in particular, seem to me to show that the
puncture of the eye offers us then some undeniable advantages, and that the
moderns have exaggerated its possible bad results.
2. Hydrophthalmia. — The puncture of the eye for hydrophthalmia, whether
attended or not by the liquefaction of the vitreous humor or the extravasation
of blood or pus, is a means of relief not so often resorted to at the present
time. It would be imprudent, doubtless, to commence the treatment by it;
but when general therapeutic means and topical applications have been tried
without success, and the distension of the eye continues, I can see nothing
more rational than paracentesis of the eye. By removing the compression of
OPERATIVE SURGERY-. S7S
tlie retina, the iris, the ciliary circle, processes, vessels, and nerves, it calmg
the most violent pains, and appears to me capable of preventing most serious
consequences and becoming a most important palliative, if not curative means.
Though used in Japan and China for some centuries, and practised by
Tuberville and Woolhouse, this remedy does not appear to have been formally
proposed by any one for hydrophthalmia, before Yalentini, Nuck, and Mau-
chart. Woolhouse advised the puncture of the sclerotica, and Nuck of the
centre of the cornea. 'Puncturing, properly so called, is now generally
abandoned. It is in almost every case advantageously superseded by inci-
sion. Some prefer to open the anterior, others, M. Basedow for example, the
posterior chamber. Bidloe opened the inferior part of the cornea with a
hawk-billed lancet. Meckren used a large triangular needle made for
the purpose. At the present time a cataract-ceratotome is most usually
employed. Saint Yves divided the cornea transversely. Louis dislikes too
large an opening. Heister advises the incision of the sclerotica. Others are
for puncturing first, and extending the opening with scissors or some other
instrument. But amongst the whole the choice truly lies between Bidloe's,
or rather Galen's method, and that of Maitre-Jean and Heister. None of
the others accomplish the purpose so well, and most are more complicated or
much more dangerous. The incision of the sclerotica either outwards or
downwards, or parallel to the fibres of this membrane, reduces itself in effect
to a trifling puncture, and would be preferable if the aqueous humor could
always escape thereby. But unhappilj this is not the case. Even in simple
hydrophthalmia it is evidently necessary in dividing the sclerotica, to do the
same with at least two lines of the ciliary circle, which must make this ope-
ration more dangerous than the division of the cornea. It is only then when
the disease affects the vitreous body — differing from simple hydrophthalmia —
that Heister's method offers any advantages; yet even in that case it is of little
importance which be pursued, as the eye is in most cases utterly lost.
Operation. — Having disposed the patient and assistants as if for the extrac-
tion of a cataract, opened the lids, and fixed the eye, the surgeon, with the
point of a lancet, bistoury, or ceratotome, held as a pen, makes an incision of
two or three lines through the inferior or external part of the cornea, as far
from the pupil as possible without wounding the iris. The aqueous humor
soon escapes ; there is no nec3ssity for pressure. A very manifest relief is
generally the immediate consequence. As there may be some hope of saving
the eye, nothing should be done to prevent the cicatrization of the wound. It
should be dressed as an operation for cataract, and the puncture renewed
after some days (according to M. Basedow, who reports four instances of
success), if a new accumulation of fluid seems to require it. No one would
now advise us to imitate Nuck and some of the surgeons of the last century,
in putting a plate of lead between the lids in order to press the eye back-
wards and make it gradually retire into the orbit. Such a practice, in itself
unworthy of discussion, could only have been adopted by those who confound
exophthalmia, buphthalmia, and proptosis with true hydrophthalmia.
If some point of the tunics of the eye be more manifestly altered, promi-
nent, or thinner than the others, it sliould certainly be preferred to the point
above indicated for the paracentesis. When in buphthalmia the projection
of the eye depends upon dropsy, upon a forced dilatation of the sclerotica, it i&
S74
NEW ELEMENTS OF
still hjdrophthalmia, and indicates the same operation as above. On the con-
trary, it will be of no use, and will only aggravate the condition of the patient
when the disease is caused by the development of some humor, or by tho
existence of some organic lesion of the orbit.
3. Hypopyon. — Galen seems to have been the first to propose paracentesis
for hypopyon. Yet he did not have recourse to it until after having vainly
tried succussion, so much extolled by Justus, and which Heister and Mauchart
since have not disdained to try. According to this author, the inferior part
of the cornea is to be opened a little anterior to its union with the sclerotica, and
the pus soon flows fordi. Aetius advises the use of aneedle at some point of
the membrane that is uninflamed. G. de Chauliac, Benedetti, Pare, and
Dionis have followed the direction of Galen with success ; and in spite of the
efforts of Nuck, Woolhouse, and many others, who, like the Arabians,
advised us to be content with a puncture to give air to the matter; who even
go so far as to recommend leaving a canula in the place, which may be used
for making injections into the eye, modern operators are satisfied with a
clean and simple incision, when they have decided to treat hypopyon by
paracentesis. This would be in fact the best method in such cases, if any
operation be necessary, or if we are to believe M. Gierl on this subject. But
the great masters of the present time unite in condemning all species of sur-
gical interference; saying, with reason, that the small quantity of pus which
forms hypopyon will disappear quite soon of itself when the ophthalmia is
reduced ; that a way to augment the secretion and produce opacity of the
cornea, is to open the anterior chamber with an instrument of any kind; that
the chronic purulent deposites — the only ones perhaps that paracentesis
does not aggravate — are formed of a matter too firmly adherent either to the
iris or the cornea to be made to escape by an incision of some lines in extent;
that we should trust to general treatment and collyria to arrest such disease
while it is yet within the bounds of true hypopyon, while there are yet hopes
of preserving the function of vision. For these reasons I think, with Boyer,
Richerand, and Dupuytren, that the puncture of the eye is but rarely appli-
cable to abscess of the anterior chamber, unless we employ it, like Lehoc, to
renew the aqueous humor as well as to evacuate the purulent matter.
4. Empyesis. — In abscess of the posterior chamber, that is, in empyesis or
empyema of the eye, it would seem at first sight that all must agree upon the
necessity of having recourse to paracentesis. But this would be a mistake.
Many have advised it. Almost all the surgeons of the last century practised
it frequently. Yet it is in fact a feeble resource. By this means we can
only imperfectly evacuate the morbid collection. As it is soon reproduced,
the evil is hardly removed for a few moments. The eye once in that condi-
tion is lost without resource. Incision is of no greater advantage. It is neces-
sary to excise a portion sufficiently large to empty the eye and determine
atrophy of that organ. The seton used in China and Japan, extolled by
Woolhouse, and lately again brought forward by Mr. Ford, &c., is a barbarous
means unworthy of criticism. It can scarcely be conceived how it could
enter the mind of any man to traverse the anterior or posterior chamber from
the external to the internal angle, with a needle drawing after it a cord which
is to be tied by its two ends in front of the eye, to cause the escape or the dis-
sipation of the empyema. The dangers and uselessness of such a proceeding
are too evident to need pointing out.
OPERATIVE SURGERY. 375
§ 6. Recision.
Staphyloma of the cornea, empyema, hypopyon, and iiydrophthalmia, are
almost the only diseases requiring excision of the anterior portion of the eye,
or for which it can be reasonably tried.
Its object is to empty the organ, to produce atrophy, and thereby transform
it into a simple stump capable of supporting an artificial eye. It is the last
resort, only permitted in a hopeless case to remedy a most serious disease or
a shocking deformity, and only when it is demonstrated that sight can
neither be preserved nor restored. In hypopyon, empyesis, and hydrophthalmia,
it is to be resorted to only after trial of incision or puncture, and when these
have proved insufficient. The most ancient authors used it in procidentia
oculi. Galen speaks of it as a common method. Aetius recommends it to
be combined with ligature ; and that before removing the staphyloma two
ligatures should be passed through it. The ligature may be circular, crucial,
or transverse, like that of Paul of Egina, and others ; the taxis and compres-
sion of Manget, and the crucial incision of Woolhouse, are none of them now
in use. The surgeons of the present day, when they wish to obtain a perfect
cure of staphyloma of the cornea, follow the advice of Pare and Louis, that is
to practice a clean and simple incision.
Operation. — For whatever disease it may be, if we object to taking away the
whole organ, we should confine ourselves to removing the summit. Cancerous
affections, if they ever admit of a simple recision, form the only exception to
this rule. By carrying the plane of the incision through the posterior cham-
ber, as some oculists have done, the muscles are apt to draw what is left of the
sclerotica and optic nerve to the bottom of the orbit, leaving us without a
stump after recovery. On the other hand, if the opening be too small, the
morbid or natural humors only partially escape ; the w^ound soon cicatrizes,
and leaves a depression as unsightly perhaps as the staphyloma itself, besides
rendering it difficult to use an artificial eye. AVe escape these two extremes
by taking the whole of the cornea, and nothing more. Then we are sure that
the vitreous humor will escape or disappear, and that no new accumulation
producing painful distension will be formed in the posterior chamber. The
iris being preserved, it is evident that the sclerotica cannot become everted
nor sink into the orbital cavity; and that after cicatrization the muscles can
impress upon the organ the most of its natural movements, and transmit them
to the artificial eye. The crucial incision with excision of the four flaps, as
recommended by Richter, is altogether useless. The patient being suitably
placed and supported, the inferior half of the cornea is to be divided with
Daviel's instrument, the point of a lancet, a bistoury, or ceratotome of any
kind, as if for extraction of the lens. The flap is then seized with any good
forceps, and fully detached by means of sharp scissors or a bistoury. With un-
manageable subjects, or when the eye is difficult to fix, a hook fastened into
the middle of the segment renders the excision more sure and prompt. This
process is more simple tlian that of Terras, who passed a ligature through the
tumor in order to cut it off more easily and permit us to remove as rapidly
as possible, and with a single stroke of a bistoury, the whole of the cornea or
staphyloma ; beginning eitlier above or below. The ring and blade of M. De-
mours is not more convenient and deserves no preference.
376 NEW ELEMENTS OF
The consequences of this operation are commoijly active inflammation of all
the parts within the orbit, fever, headache, and sometimes even same symp-
toms of a much higher grade. In general, however, after about ton or fifteen
days, the swelling begins to decrease ; the suppuration, at first very abundant,
does not last long, and towards the enil of a month, a little sooner or a little
later, it is possible to put in the artificial eye. As this is not an operation with-
out danger, those who desire it to be performed for simple deformity should
be informed of its nature ; nor should it be performed in such cases except at
their solicitation. But on the contrary, when the. disease is dangerous of itself,
such as empyema, hydrophthalmia, &c., there is no room for hesitation ; every
fear must disappear in the presence of such affections.
§ 7. Extirpation,
Although extirpation of the eye was not clearly described until towards
the close of the last century, there is every reason to believe that the older
surgeons had frequent recourse to it: thus J. Lange, who wrote in 1555,
boasts of having preserved an eye which surgeons wished to extirpate. A
little later, in 1583, M.Donat attempted to demonstrate its inutility, and main-
tained that compression, aided by proper internal remedies, almost always
triumphed over such affections as seemed to require it; which proves at least
that it had been long known to practitioners. Bartisch, who published his
book in 1583, has not then the merit of its invention, but only of calling
attention to it and rendering the operation more easy. Some authors, Covil-
lard, Lamswerde, and Spigel for example, pretend to have cured without an
operation subjects whose eyes had been violently forced from the orbit and
hung upon the cheek. Maitre-Jean long since showed the impossibility of
such an occurrence according to the letter ; but Louis has well remarked, that
disrobing these assertions of their hyperbole, some proof in their favor is
found in the fact that the optic nerve and the surrounding muscles can bear
considerable elongation without requiring the extirpation of the eye. Besides,
there are numerous examples of this elongation produced in a gradual manner
by some cases of exostosis, by tumors of all kinds in the orbit, nasal fossae, and
maxillary sinuses. But if the ej'^e really hangs out from the orbit in conse-
quence of some traumatic lesion, instead of seeking to replace it we should
completely separate and remove it at once. In such cases there is no method
to describe. A single cut with the scissors or bistoury is sometimes sufficient;
in others the surgeon must necessarily vary the process to suit the accident. On
the contrary, when the eye has been forced from the orbit by degrees, either
entirely or partially, and whether it be itself disorganized or not, it may be
wrong to extirpate it. It is not to it that we must apply our surgical means.
It is the business of the surgeon to destroy the original cause if he can, and
then the displaced organ will soon return to its natural position. It was thus
that St. Yves triumphed over a dangerous exophthalmia, by determining the
resolution of a scirrhus formed in the depths of the orbit. It was by this means
that the surgeon Brossaut, of whom Louis speaks, saw the sight of an eye
restored and the eye returned into its cavity, after the oxostosis of the ethmoid
bone, which had forced it out, had been destroyed ; by this course Guerin, of
Bordeaux, and M. Dupuytren, have arrived at the same result, removing or
J
OPERATIVE SURGERY. 377
emptying the various cysts or tumors of which the parts about the eye are so
often the seat. Its extirpation then is not necessary for buphthalmia, for
hydrophthalmia, empyesis, or staphyloma. Only cancerous affections admit
of a resort to it. And it yet remains to be decided after the existence of these
is proved, whether the operation is to be attempted. Those who think
affirmatively, with Desault, &c., found their opinion upon tlie fact that the
disease is observed on infants and young persons much more frequently than
upon adults, and that at that age it is much more likely to be reproduced than
after puberty. Their opponents adduce the researches of Wardrop, which go
to prove ihaitfungus hematodes — a mixture of the encephaloid, erectile colloide,
and melaric tissues, or one of them alone, almost always constitute the disease.
And as there is nothing which reproduces itself either in the same or some
other place with more obstinacy than this kind of abnormal tissue, they
maintain that the operation gives useless pain, and that nothing should be tried
but simple palliatives. That which reason and analogy has taught them to
expect, experience has but too fully verified. Whatever some authors may
say, the labors of the ancients as well as those of the moderns, prove that
extirpation of the cancerous eye does not render it less liable to return than
the removal of a similar disease from any other part. I would not conclude
however that it is right to remain inactive. So far from it, that I think the
operation should be urged before the viscera have had time to become invaded
by the morbific germs; as soon as the disease is no longer doubtful, and when
it appears possible to remove it completely. All this, however, enters into
the general question, whether or not it be proper to operate.
Operation. — 1. Process of Bartisch. — The extirpation of the eye, which is
much more frightful than difficult, more alarming for its consequences than
fraught with immediate dangers or delicate of execution, may be performed
in various ways. We find no details upon this subject in authors before Bar -
tisch, who dug out the diseased part with a kind of cutting spoon. Although
no person at this day could recommend so coarse an instrument, yet it is not
true, as was once said, that it is apt to injure the bone and render the ope-
ration much more difficult than witii any other knife. Its dimensions do not
permit it to reach the bottom of the orbit, but I cannot perceive that it is
often necessary to go so deep. To be just, it should be discarded merely as
useless or not very convenient.
2. F, de Hilden, who had occasion to extirpate the eye, in 1596, conceived
the idea of embracing tlie projecting part at first in a kind of purse with a
draw-string. Detaching the tumor from the lids and neighboring parts with
a bistoury, he used for dividing the muscles and optic nerve a sort of two-
edged scalpel, curved sideways, broad, short, and blunt at its point, or
terminated with a button. We see in these proceedings the beginnings of a
more enlightened surgery ; and the operator spoken of by Bartholin was truly
unpardonable in not profiting by them fifty years afterwards, nor recoiling at
the thought of seizing the eye with pincers. Although more ingenious, Hilden's
instrument has yet submitted to the fate of Bartisch's. While Job a Meck-
ren succeeded with the spoon of tJie oculist of Dresden, and Muys and
Leclerc with tlie knife of Hilden, Lavauguyon maintained that a good lancet
fixed upon a handle was always sufficient, and might be substituted for them
both. Saint Yves used only a thread to fix the diseased mass and one cutting
48
378 NEW ELEMENTS Of
instrument, which he does not describe, for the whole operation. The
observations of Bidloe make no mention of any particular knife, except along
bistoury bent at an angle near the handle, and which is much extolled by V,
1). Maas.
3. Heister has shown us that a hook or forceps, and an ordinary bistoury,
with which Hoin, of Dijon, was contented in 1737, are sufficient for this
operation.
4. Such was the state of things when Louis undertook to fix the principles
for extirpation of the eye. According to him, when the tumor is retained
by nothing but the straight muscles and the optic nerve, we should use a pair
of scissors curved sideways ; these are to be carried to the bottom of the orbit
to divide the musculo-nervous attachment, and serve as a spoon or scoop to
remove the whole mass.
Desaulty who in the earlier years of his practice adopted the method of
Louis, afterwards abandoned the scissors as useless, and held to the simple bis-
toury only, with which he could effect more than with the curved one of B. BelL
Sabatier, Messrs. Boyer, Richerand, Dupuytren, and all the operators of the
present time, conform to the advice of Louis or Desault almost indifferently.
With the bistoury there is no necessity of changing the instrument from
beginning to end of the operation. The division of the soft parts is neater.
It is sufficient to draw the eye in one direction whilst cutting in the other to
reach easily the posterior part of the eye. One must be very unfortunate or
unskillful to carry the point of the instrument into the optic foramen, the max-
illary or spheroidal fissures. It is therefore here, as we have already so
often seen, a matter of choice or of circumstance, and not of necessity.
First Stage. — The patient might be seated on a chair, but it is much better
to operate upon him in bed, taking care to have the head well elevated. The
surgeon places himself on the same side with the affected eye, and conducts
himself in different ways, according as the neighboring parts are or are not
invaded by the cancer. If they are, he is to conform to the precept of Guerin,
making two semilunar incisions, which enable him to circumscribe the base
of tlie orbit and detach the lids so as to remove them with the rest of the
disease. But if otherwise, he must exert himself to preserve the appendage*
of the eye. If they have contracted adhesion without suffering any real
degeneration, he must dissect each lid away and turn it outwards. When
the globe is thus freed from them, it is sufficient to extend the external pal-
pebral angle about an inch towards the temple with a stroke of the bistoury,
as appears to have been first advised by Acrel, and not by Desault. Throughout
the whole our assistant holds the head of the patient so as to follow and favor
the movements of the operator. The latter fixes the projecting part of the
tumor with his hand if he can, as Desault did ; or uses a hook with a single
or double crotchet, hooked forceps, such as Museux's, or the purse of Hilden,
or better still, as prescribed by St. Yves, a strong ligature passed by means of
a needle through the degenerated mass.
Second iS/a^e.— Holding the bistoury in the right hand like a pen, the ope-
rator carries the point of it to the greater angle, sinks in, grazing the ethmoid
bone, to the neighborhood of the optic foramen, and then passes it flatwise over
the whole inferior semi-circumference of the orbit, separating the attachments
of tlie lesser oblique muscle, the oculo -palpebral fold of the conjunctiva, and
OPERATIVE SURGERY. S79
some cellulo-adipose filaments; then commencing again at the internal or
nasal extremity of the wound, with the edge of the instrument upwards, divides
the greater oblique muscle, and endeavors to remove with the same stroke the
lachrymal gland ; when, having traversed the roof of the orbit, he approaches
the temple and is about to unite the two incisions at tlieir outer extremity.
Third Stage. — Thenceforth the eye is held in its cavity only by the four
straight muscles and the optic nerve, forming a pedicle. If the scissors be
preferred for dividing this, the operator glides them on the internal rather than
the external side, with their concavity towards the glohe, as deeply as possible,
and witli one cut separates the cancer. If any attachments still retain it, they
are rapidly divided in the same way, whilst suitable tractions are applied
with the other hand. When the surgeon prefers the bistoury to the scissors,
he should also select the inner side for its passage. On this side, the orbitary
walls being nearly straight, it is easy, by inclining the point of the instrument
outwards, to cross and cut the pedicle. But I must state, that with the bis-
toury as well as with the scissors it is not much more difficult to accomplish
the end by following the temporal wall of the orbit. This was the route that
Desault generally took, saying it was the shortest and most convenient. A
motive more worthy of attention is, that by this we are more sure of escaping
the maxillary and sphenoidal fissures. Whether the lachrymal gland be can-
cerous or not, it is necessary, if it have not been removed before, to seize it
immediately after the operation by a hook or forceps and dissect it out. The
secretion of tears being no longer needed would only be injurious. The
surgeon then assures himself, by passing the finger into the orbit, of the state
of the remaining parts ; and if there be any unsound he should remove or
destroy them either with the bistoury, the scissors, or the scraper.
Dressing. — No large artery should have been wounded. Those that are
divided come from the ophthalmic. The ligature is not necessary even when
they bleed freely. Pledgets of lint, clean or powdered with rosin, applied
with more or less pressure, are sufficient to arrest it. The sponge proposed
by some operators in place of this substance, would have the inconvenience of
pressing the tissues too much by swelling in the midst of a solid cavity. The
little bag filled with some emollient cataplasm, as recommended by Mr. Tra-
vers, who insists upon refraining from the slightest pressure, does not appear to
be of any real advantage. At the end of four or five days suppuration is esta-
blished. The lint is then easily removed. Nothing prevents us, if it is thought
proper, from rendering the removal of the first dressings still more simple by
covering the hollow of the wound with a piece of fine linen cut in holes and
covered with cerate, which serves as a sack for the lint, and which, when the
lids have been removed, is easily turned over upon the periphery of the orbit.
A soft pledget large enough to support the deeper dressings, a pretty long
compress laid obliquely, and the monocular bandage complete the dressing,
which any surgeon may modify to meet circumstances. After the first
removal, which may take place from the third to the sixth day, the dressing
has no further peculiarity. The wound, after being washed with warm water
and softly dried, must be dressed every time with a little dry lint. The lids
slightly raised and protected by small fillets smeared with cerate, are covered
again by a soft pledget and a compress. The whole is kept in place by a
S80 NEW ELEMENTS OP
monocular or some other appropriate bandage. The cure is commonly com-
pleted between the third and tenth week.
Remarks. — Although the preservation of the eye-lids renders the deformity
less shocking, it is better to sacrifice them than to leave the least vestige of
the disease. The incision of their external angle renders the rest of the ope-
ration easier, and produces no particular ill effect. A single stitch or a strip
of adhesive plaster, will secure reunion. If the operation is commenced by
the superior incision, the blood must somewhat embarrass the operator in
cutting below. When the eye only is affected it is not necessary to carry
the instrument more than an inch deep. But it is necessary to go to the apex
of the orbit when morbid adhesions have been formed between the soft parts
and the bone. Then the spoon of Bartisch, the knife of Hilden, and the bis-
toury of Bidloe will expose us to fractures, which it is always best to avoid.
At this point, too, any sharp instrument used without great caution may pene-
trate through the frontal bone into the brain, especially if to reach the levator
muscle or the lachrymal gland we elevate the point too much; enter the
maxillary sinus and divide the infra-orbital nerve or vessels, if we carry it
too far in the opposite direction ; penetrate into the nasal within ; the zygo-
matic or pterygo-maxillary fossa behind and without, and reach the second
branch of the trigeminus nerve, or the internal maxillary artery ; or into the
cranium again by the sphenoidal hole, and touch the middle lobe of the brain.
Yet if the bistoury should not scrape the bone it will not be sure to remove the
whole of tlie cancer, but may require a subsequent excision. The lachrymal
gland particularly, being almost entirely hid behind the external orbital process,
is not easily removed with the eye. The scraper of Bichat, or a chemical
caustic, will be less dangerous than the actual cautery, if either of them be
indispensable for the removal of the soft parts ; at least in the roof of the
orbit. In fact, the proximity of the brain would render the use of the actual
cautery Y^ry dangerous. Although it be the common practice to use the same
hand for both incisions, it would seem more convenient on the right eye for
example, to use the right hand for the lower, and the left for the upper
incision, unless the latter be carried from the temple towards the nose. The
levator palpebrae muscle should be cut; because, if left it tends continually to
draw the upper lid inwards after the cure, thereby augmenting the necessary
deformity. I had almost forgotten to say that M. Dupuytren begins witli the
superior incision, and finishes by detaching the organ from the apex towards
the base of the orbit.
Artificial Eyes. — Nothing would be more desirable certainly than to be
able to use an enamel eye, when the disease enables us to retain the lids in
their integrity ; but we should not flatter ourselves too much with such hopes.
The orbit, like all natural cavities, once emptied contracts upon itself; its
walls approach each other from the bottom towards the exterior ; the circum-
ference lessens, so that after a certain time the vault becomes completely
effaced with this coarctation and the deposition of fibro-cartilaginous matter.
Obliged to follow, the eye-lids contract adhesions by their posterior face, are
deformed, and become most frequently incapable of applying themselves to
the artificial organ which we would place behind them. Consequently,
whether the lids be removed or not, we must expect to be forced, if the patient
OPERATIVE SURGERY. SSt
desires to hide his mutilation, to use spectacles, skillfully furnished with a.
colored plate of metal to be fixed over the obliterated cavity. In former times
they bestowed more pains upon them than we do. They had two kinds of
artificial eyes : one like ours, to be placed behind the lids ; the other, used
from the time of Pare, who is said to have been the first to speak of it, a kind
of convex plate, on which the anterior part of the eye and its appendages
were painted, and which was held in place by means of a spring. Formerly
the first were made of gold or silver ; now enamel is justly preferred. Upon
this must be represented the cornea, iris, pupil, sclerotica, and the vessels. In
order to apply it, take it by the extremities of its greater diameter between
the thumb and first finger, and carry it to the edge of the superior lid, jvhich
is gently raised with the other hand. It enters then as it were of itself, when
the lower lid is depressed. In order to remove it at night on going to bed, the
patient slips under it the head of a pin, draws down the inferior lid, and pulls
it forwards. It should be deposited in a glass of water for the night, and be
cleansed and dried carefully every morning before being replaced. I need not
say that its dimensions should be adapted to the orbit of the particular indi-
vidual, and that it is better to renew it whenever it begins to change. When
the enamel is good, and the two posterior thirds of the natural eye remain to
constitute a stump, the resemblance is sometimes so striking that it produces
a complete illusion. In the other case, as there is nothing to move it, it
remains permanently fixed in the centre of the eye, and unhappily it does
not prevent us from distinguishing those who are obliged to use them.
SECTION III.
The Mouth.
Jrt. 1.— 7%e Lips
§ 1. Hare-lip,
The labial fissure known by the name of hare-lip, is either acquired or
congenital. When it occurs after birth, it is observed as frequently on one
lip as on the other; but the second variety has scarcely been seen except upon
the upper. The case of Nicati, who professes to have met with it on the
lower lip, is certainly an exception. Since Louis interested himself in prov-
ing that the hare-lip is not attended with any loss of substance, Blumenbach,
Tenon, Beclard, Meckel, &c., have attempted to explain its formation by
certain laws of organization, considering its several grades as a cessation of
development. At first, according to some, three portions compose the upper
lip, a middle and two lateral. There might even be four according to others,
who make the middle portion originally divided into two parts. In this
hypothesis one of the embryo fissures of the lip is supposed to remain in the
case of simple hare-lip; and the proof they say is, that it is almost constantly-
found on the median line. When the two lateral portions remain isolated from
the middle portion, the hare-lip is neces^^sarily double. If the authors of some
observations already ancient, and more recently Moscati, are not mistaken ;
if they have really seen the leporine fissure in an exact line with the septum
582 NEW ELEMENTS OF
of the nose, this may be explained by admitting the non-union of the two
portions of the middle lobe of the lip. Lastly, as to the lower lip, a con-
genital hare-lip will always occupy the median line, because in its origin
there are never more than two portions. Numerous researches upon embryos
and foetuses of every age, induce me to believe that these inaccurate ideas are
the result of erroneous observations or gratuitous suppositions. The lips are
no more composed of two, three, or four pieces, at three, four, six, or eight
weeks than at three or four months. From the moment they begin to appear
they seem as entire as the buccal opening which they exactly bound. The
contrary only occurs accidentally. The hare-lip, like most other monstrosi-
ties, ought in my opinion to be referred to disease much more frequently^ than
to a defect of natural development.
CHEILORAPHY.
A. Simple Hare-lip,
a. History, — Although the hare-lip is one of the most common deformities
of infancy, it scarcely occupied the attention of the ancients. Celsus is the
j&rst who mentions it, and he rather confusedly. The Arabians scarcely
notice it, and it is clear that until the times of Franco and Pare its treatment
did not attract all the attention that it deserved. At present, on the contrary,
it forms a part of practice to which nothing further seems wanting. For its
cure three indications are to be fulfilled. The edges are to be made raw, its
two sides are to be brought evenly together, and the two lips of the division
are to be kept in perfect contact until they have become agglutinated.
1st. It was with hot iron, that Abul-Kasem, as well as Ludovic, produced
the state of rawness in the hare-lip. The butter of antimony or some other
caustic was preferred by Thevenin. Chopart, yielding in this to the advice
of Louis, expected to succeed better by applying two vesicatory strips to the
edges of the fissure. Such means only deserved and actually met with but
incomplete success. They have been justly abandoned. ExcisioUy which
has been in use from the time of Celsus and Rhazes (this, however, did not
prevent Fabricius ab Aquapendente from confining himself to simple scarifica'
tions), is the only method admitted at the present day. In performing it,
D. Scacchi and Dionis used common scissors; Henkel, button -pointed ones.
But M. A. Severin and Acrel gave exclusive preference to the bistoury,
which Louis and Percy have strongly endeavored to bring into general use;
while Roonhuysen, Le Dran, and B. Bell, had recourse indifferently to either
of these two instruments. The advocates of the bistoury contend that it
produces less pain, and makes a wound much neater and less inclined to sup-
purate ; that the scissors cut more by pressure than actual incision ; that they
bruise the tissues and produce a wound of two oblique planes like a double
roof, by no means favorable, from its shape, to immediate union. Experience
has a thousand times demonstrated the futility of these objections. To be
assured on this point, Bell operated on one side with the scissors and on the
other with the bistoury, without explaining his intention. The patient was at
first embarrassed, in deciding, but at last declared that the pain was greater
in the part where the bistoury had been employed. The scissors have an
advantage, in requiring no support, in being more easily managed, and in
OPERATIVE StTRGERY. 583
cutting off at one stroke all that is to be taken away. Desault, who has
strongly ; advocated them, recommends them to be made of considerable
thickness and much hollowed in the blades. Those which are now pre-
ferred bear the name of M. Dubois, and are constructed on this principle.
For the purpose of giving greater advantage to the power which moves them,
the handles are made comparatively long; the blades are short and solid,
and thus cut with great neatness and all desirable precision. This is the
only instrument used in France.
Nevertheless, it would be wrong to conclude that the bistoury is not suf-
ficient. Louis has afforded proof enough to the contrary, and many practi-
tioners of Germany and England are still in the constant habit of employing
it. The manner of using it, has singularly varied. At the instance of
Guillemeau, Le Dran commenced by inserting its point, from the mouth
towards the skin, through the lip a little above the summit of the division ;
he then cut perpendicularly from above downwards, or from behind forwards
as far as the labial border; and did the same on the opposite side. B. Bell
reversed this process. Placing himself behind his patient's head, he began
his incision at the free edge of the lip, carrying it upwards and backwards
to a point above the abnormal fissure, holding his bistoury as a pen. Enaux,
after destroying the adhesion between the alveolar arch and the lip, passed
behind the lip a plate of cork to give support to the action of the bistoury. A
fold of paper, a common playing-card, or a thin piece of white wood, will
very well supply the place of the bit of cork of Enaux. The forceps or
pincers, whether of metal like those of J. Fabricius, or of wood like those
used by M. A. Severin, which serve to fix the lip while the section is being
made, and which by the greater breadth of their posterior branch were able
to supply the place of the pasteboard required in the use of the bistoury, and
the intention of which was also to aid in the approximation of the two cut
borders and prevent hemorrhage, have long since been rejected from prac-
tice. Heister, B. Bell, and 0. Acrel, are, I believe, the latest autliors who
have thought proper to recommend them. ^
2d. After the borders are made raw, the hare-lip is found retTtK^ed to the state
of a simple wound, and its union is to be immediately attempted by the aid of
appropriate bandages or the suture, or by combining both these means. Franco,
who was satisfied with the plasters of Andre de Lacroix fixed upon the cheeks
ind narrow ribands crossed beneath the nose constituting what he termed the
dry suture, and then a retaining bandange ; F. Sylvius, who, according to Muys,
succeeded with adhesive strips alone, supported also by a bandage; Purman
and G. W. Wedel, who it is said were not less successful; have found in
Pibrac, but particularly in Louis, an ardent defender. According to this au-
thor, the bloody suture is not only useless but even injurious. Useless, inas-
much as the hare-lip being unattended with any loss of substance, must always
be susceptible of approximation by the uniting bandage of rectilinear wounds;
injurious, for its presence is a permanent cause of irritation, which cannot
fail to excite muscular retraction. In accordance with this principle, Louis
employed a single point of interrupted suture, and a simple bandage to complete
the union. The ideas of Pibrac, who wished in some measure to proscribe the
suture from surgery, seemed to find here a just application. To produce a
complete coaptation Valentine invented a clasp, a kind of double flat forceps,
capable of embracing the two sides of the wound without destroying their
384 NEW ELEMENTS OF
parallelism, and of being approximated at pleasure by means of a transverse
piece and a screw. To prevent the contusion and the unequal compression which
the instrument of Valentine was apt to produce, Enaux proposed a bandage,
the model of which is still preserved in the museum of the Faculty of Paris,
and which being applied over the nape of the neck, the vertex, and beneath
the lower jaw, by as many segments of circles, presents two cushions which
are to push forward the parts when applied to the cheeks, and may be united
by passing a strip in front of the wound from one to the other. Evers rejected
all these means, and confined himself to emplastic strips, crossed beneath the
nose in the form of St. Andrew's cross; and M. Dudan has since invented
with the same view a new clasp, founded on the same principle with that of
Valentine. No doubt the hare-lip is sometimes cured in this manner; but^
it is also certain that more frequently the union is bad and incomplete ; thafw
there often remains a groove of more or less depth either in front or behind ;
and a gap is left quite open below, almost as disagreeable as the original disease :
while the bloody suture, properly performed, avoids all these disadvantages.
On this account it is almost exclusively practised in our day, and bandages
are no longer advised but as auxiliaries.
Celsus, who sewed the hare-lip, does not give details enough to let us un-
derstand what was the kind of suture employed in his time. It is probable
from what is said of it by Albucasis, that the Arabians used the gloverh su-
ture. Others, Heuermann, Ollenroth, and W. Dros, for example, have advised
the interrupted suture, which was also preferred by Lassus, in order to
avoid leaving inflexible bodies in the wound. There is none, even to the quilted
suture, which has not had fts partisans, although the twisted suture has almost
always maintained the preference. Ambrose Pare, the first author who de-
scribes it in precise terms, performed it by means of needles furnished with
eyes, which he carried through the wound from one side to the other, and then
fixed by turns of thread, passed in the form of the figure 8, over the two ex-
tremities. Fabricius ab Aquapendente used flexible needles, the extremities
of which he bent forwards after their insertion. Those of Roonhuysen were
angular or triangular, like those of Pare ; he wound them with silken thread,
and cut off their points with nippers. Dionis used them of steel, and curved.
Instead of taking off their points, like Roonhuysen and Dionis, La Charriere
merely placed a small compress between their extremities and the skin. For
the purpose of introducing them without trouble, notwithstanding their fine-
ness, Heister made use of a porte-aiguille; and J. L. Petit, who used them
stronger, and furnished the two extremities of each with a head, caused them
to be made of silver, which he introduced by means of an instrument resem-
bling a larding-pin. Le Dran employed gold pins, so that they might be at the *
same time solid and strong and not liable to be oxydized ; their points were
flattened and they were furnished with a head in order to dispense with the
porte-aiguille. If gold and silver have the advantage of not rusting, they
have the disadvantage when used in cutting instruments of not passing through
the tissue witli facility. For this reason Sharp soldered to his silver needle
a lance-shaped point of steel. Wedel contends that common needles will
serve, and should be wound afterwards with a hempen thread. Without so
much preparation, de la Faye asserts that copper pins stout and long, in a
word, German pins, are better than all others. As their points might wound
the patient, Mursinna recommends that they should be guarded afterwards
OPERATIVE SURGERY. 385
v/ith small pieces of quill. Le Dran found it more convenient to use small
balls of wax. Arneniann employed hollow pins from which the head and point
could be removed at pleasure. Desault's, which are of silver with steel
points, diminish in size from their cutting extremity to that which is to support
the action of the finger, in order that they may be extracted without repassing
them by the same way that they entered, and without again drawing the blades
through the flesh. It is this kind that, in France at least, has united almost
every suffrage. Indeed we see no reason to object to them ; except that good
common pins, such as are to be found everywhere, will answer the purpose
equally well, if, before inserting them, care be taken to grind them so as to
flatten the point by rubbing them on a tile or stone vase, or any other piece
of stone.
As to the semilunar incisions with their concavity anteriorly, which Celsus
performed on the interior of the cheek, and which Guillemeau, Thevenin, and
Manget performed on the exterior ; the dissection of the posterior face of the
lip, which J. Fabricius and D. Scacchi have pointed out as favoring the
approximation of the borders of the hare-lip ; they should be no longer men-
tioned in simple cases, unless to show their absurdity and barbarity. It is
not so, however, with the idea of preparing the parts beforehand for approxi-
mation. Instead of the forceps of Fabricius, &c., V. D. Haar, and after him
Arnemann, and Knackstedt of St. Petersburg, have proposed a bandage, which
being worn for a week or two is capable of bringing towards the median line
those points the ultimate contact of which is to be effected. It is rare,
nevertheless, that the moderns feel obliged to follow this indication, knowing
that the common uniting bandage will attain exactly the same end. Unless
the separation be extrenie, the immediate coaptation of the sides of the wound
presents in general but very few difficulties.
Apprehensive that, notwithstanding the suture, the parts might afterwards
retract, surgeons of diff*erent times have labored to find means to obviate
this inconvenience. Hence the load of apparatus with which the science is
overburdened, and the association of the dry suture or bandages with the bloody
suture. On this point Dionis seems to have set the example. He placed an
adhesive plaster upon his twisted needles and supported the whole by a four-
tailed bandage. By means of a circle of steel which passed round the head,
and graduated compresses which he fixed upon the cheeks. La Charriere
considered success infallible. As substitutes for his bandages as it was after-
wards modified by Quesnay, Heister, Henkel, Koenig, Stuckelberger, Eck-
holdt, &c., Enaux, Valentine, and Beind constructed those which bear their
names, but which have entirely yielded to the bandages of Louis and
Desault. Without being indispensable, the retaining bandage, such as is
generally used among practitioners of the present day, has the undoubted
advantage of protecting and aiding tlie action of the needles, and of render-
ing disunion of the parts much more difficult in unmanageable subjects.
When we dispense with it, like the ancients, or, like Le Dran, limit ourselves
to the use of a strip of adhesive plaster, extending from one temple to the
other, and running beneath the nose in the way that English practitioners,
vidth Beclard, &c., still prefer, its inutility is its only fault ; for how it can be
injurious does not appear.
b. Operative Process.— The following is the mode of performing this ope-
49 " " "
♦ '«#
386 NEW ELEMENTS OF
ration : The apparatus consists of a hook ; a pair of dressing or dissecting
forceps ; a pair of hare-lip scissors ; three, four, or six prepared needles ; a*
single waxed thread two or three feet long ; another thread of three or four
strands and twice as long as the first ; small rolls of diachylon or linen to
place on the extremities of the needles; a small pledget of lint spread with
cerate ; two compresses a little longer than broad, and folded six or eight
times, to be applied to the cheeks ; a double-headed roller an inch wide, and
long enough to make four or five turns of the head ; a sling or four-tailed
bandage; adhesive strips in case the bandage is not to be employed; and a
playing card and a straight bistoury if the scissors are not to be used.
First Step, — The patient being placed on a chair in a good light, has his
head held firmly by an assistant in such a manner as to enable him at the
same time to compress the external maxillary arteries beneath and in front of
the masseters, to push forward the cheeks towards the median line, and hold
the lip, if necessary, while the operator makes his incision. A second
assistant is charged with handing the several parts of the apparatus as they
may be required. Seated or standing before the patient, the surgeon passes
a thread through the left inferior angle of the division, as advised by Koenig,
unless he prefer inserting a pin or holding it with a hook, as practised by M.
Roux, or merely to use the pincers or the fore-finger and thumb of the left hand
to fix it. The scissors, held in the other hand, are then carried two or three
lines higher than the superior angle of the fissure, separating all the rounded
portion at a single stroke if possible, and encroaching even a little on the
sound parts so as to make a wound fresh, straight, regular, and perpendi-
cular. On the other side he stretches the lip itself, by seizing and drawing it
with the thumb and fore-finger placed without the border to be excised. The
scissors, guided as before, are to be raised with their point as high as the
superior extremity of the first wound, and even a little higher, in order that
the two little strips which are to be insulated, and which by their union
represent an inverted V, may be immediately freed from all adhesion up to
their nasal angle. Nevertheless, if at this point a pedicle should remain,
all endeavor should be made to leave it of the least possible .thickness, and
with a third stroke to cut it as high as possible ; otherwise this part of the
wound being too round, will only with difficulty admit of exact coaptation.
Second Step, — ^To make the suture, the operator again takes hold of the
right angle of the division with the fore-finger and thumb of the left hand,
and with the right carries the point of the first needle to a point on the skin
half a line above the red border of the lip, and three lines outwards from the
raw edge ; he then enters it a little obliquely from below upwards, from be-
fore backwards, and from the skin towards the mouth, so that passing through
the tissues it may come out at the union of the anterior two-thirds with the
posterior third of the bloody part ; then changing its direction, he pushes it
through the other lip from behind forwards, and from within outwards, so that
its entrance and its exit may be on as exact a level as possible, and that in
its whole course it may describe a slight curve, the convexity of which will
look a little backwards and upwards. Its two extremities are then included
within a noose of the single thread prepared for this purpose, which allows
the assistant in charge to stretch properly the whole extent of the lip while
the surgeon fixes the second needle. This, which is usually the last, is to be
OPERATIVE SURGERY.- 38?
inserted at an equal distance between the first and the superior angle of the
hare-lip. It is not necessary, as with the first, to make it describe a curve,
nor to carry it separately through the two parts of the division. It is pushed
through transversely with the right hand, while the fingers of the left pre-
serve the two edges of the wound in exact coaptation ; always taking care
to enter it and bring it out of the skin at about three lines from the solution
of continuity. It is embraced immediately after with the middle portion of
the doubled thread, the operator using both hands. The two ends of the
thread are then carried round in turns, crossed in the form of the figure 8 ;
afterwards brought back, forming an X, beneath the inferior needle, which is
wound in the same manner ; and thus in succession from one to the other,
until the thread is exhausted or the whole of the wound concealed by the
figures 8 and X which it has formed. In conclusion, the two ends are
arranged so as to be brought under the head or point of the superior needle.
TTiird Step. — The first thread being no longer of use is cut by the surgeon,
who then places between the integuments and the metallic ends little pro-
tecting rolls, or the pledget of lint, the fillet of diachylon, or the bandage if
he mean to use it. In this case he applies the body of the bandage to the
M iddle of the forehead ; carries its two heads below the occiput ; crosses
them and changes hands ; brings them back above the ears upon the square
compresses which the assistant holds upon the masseter muscles ; carries them
to the. sides of the nose ; makes a slit in one of the heads of the bandage oppo-
site the wound, through which to pass the other and cross them more easily;
carries them behind above the nape of the neck, crosses them again, and
finishes by circular turns round the head. The string, or four-tailed bandage,
which is to fix the whole is first applied with its body to the chin. The two
inferior ends are carried up in front of the ears, over the genal compresses
as far as the vertex, where they are made fast. The two remaining ends are
carried horizontally backwards, crossed at the occiput, and brought forwards
on the forehead.
Subsequent Treatment, — This being done, the patient is put to bed, where
he must rest quiet, without speaking or attempting the least motion of the
jaws for three or four days. His diet must consist of broth, light soups very
liquid, or some kind of ptisan. At the end of three days, if all goes well,
the superior needle may be removed. On the fourth the inferior one may
also be taken away. The coil of thread adhering to the skin being left in
place a day or two, allows the cicatrix to become more and more consolidated.
When it is disengaged from the front of the lip, it may be supplied by an
adhesive strip if there be any fear that the union is not sufficiently firm.
Towards the ninth or tenth day the cure is generally completed. After the
fourth day there is no objection to soups a little more substantial, or to the
patient's rising and walking about.
c. i?emarA;s.— Before commencing the operation, it is almost always necessary
to divide the fraenum of the superior lip, which however is not attended with
the least difficulty. It cannot be dispensed with if scissors are to be used,
except in cases in which the fissure is of little deptli and situated without the
median line ; nor does the bistoury admit of any exception on this point unless
we dispense with the card. When this is employed, the fraenum is divided
and the card is placed as high as possible between the maxillary bone and the
388 NEW ELEMENTS OF
lip. After fixing the left border of the hare -lip upon the card bj holding it
at its inferior angle, the point of the instrument, which is held as a pen, is
carried to the.part where the incision is to commence, where it is inserted per-
pendicularly, the handle gradually depressed, and a single stroke cuts through
the whole length of the fleshy border contained between its edge and the card
which prevents it from penetrating the mouth. To cut off the other border,
the surgeon seizes the lip beyond the line of division, unless he can use his
left hand sufficiently to perform with it what he has done on the other side
with the right, carrying in every case the point of the bistoury to the supe-
rior angle of the first wound, and terminating the incision on this side as on
the other. The compress which Lavauguyon placed between the lip and the
gum to prevent adhesions of this latter ; rejected as useless, or else as danger-
ous by Le Dran, proposed again by Heuermann, is not used at the present
day ; nor the plate of lead advised by Eckholdt for the same end. Cases in
which the lip has been detached to a great extent from the maxillary bone, are
the only ones which give an excuse for its application.
It is useless to apply so many as five needles, as recommended by Roon-
huysen ; two are generally sufficient ; and it is not absolutely necessary that
the superior one should be at the superior part of the wound, as adv\ged by
Le Dran. De la Faye and Mursinna, who direct to commence with the supe-
rior, no doubt forgot that the two labial extremities of the division are thus in
danger of not being on a level. De la Faye himself was obliged to cut off
afterwards the unsightly tubercle which resulted from this mode of operation
in one of his patients. Without conforming entirely to the principle of Le
Dran ; without plunging the inferior needle in the vermilion border of the lip
(a rent would almost inevitably be the consequence), yet it must be known,
that at more than a line above, union might well prove incomplete and a little
gap be left below. If it does not penetrate near the buccal surface of the
organ, agglutination will only take place in front ; a furrow or groove of more
or less depth will remain behind, and render success very imperfect. The
bleeding parts not being in contact, nor pressed upon equally through their
whole thickness, may sometimes be the cause of hemorrhage. On the other
hand it is easily perceived how troublesome it would be to pierce each half of
the lip entirely through. In making the needle describe an arch, the object
is to depress the tissues on the median line a little more than on the sides, in
order to reproduce as much as possible the tubercle, the little projection which
there naturally exists. Curved or flexible needles would be incapable of
fulfilling this indication.
" Although, as a general rule, it is necessary to cut off rather too much than
too little, and to prolong the wound, according to B. Bell, nearly to the nose,
yet it is sufficient, when the gap is of little depth, to take away all the red
border and reduce the hare-lip to the state of a recent wound with loss of
substance, exactly triangular, and with edges of the sartie thickness throughout.
If the eifusion of blood from the coronary artery, which is at first copious, will
not yield to compression of the facial on the edge of the jaw, the assistant has
but to compress the corresponding half of the lip to arrest it. The ligature
is never indispensable here, nor the cautery. When the cut edges are brought
together the hemorrhage ceases ; a defect of contact in some point or others
or some unforeseen accident, will alone permit it to continue. For the rest.
OPERATIVE SURGERY. S89
the surgeon would be blamable not to have an eye on it timing the first few-
hours following the operation, particularly in children. Indeed, instead of
being rejected, the blood is swallowed by them as it flows imperceptibly into
the mouth, and in this manner, Platner says hemorrhage remains unperceived,
and may, according to examples cited by J. L. Petit and Bichat, go so far as
to produce death. Before applying the bandage it is well to cover the head
with a cotton cap, so fitted as not to be easily deranged ; to have the head well
combed, and, as practised by Desault, to rub in a little mercurial ointment to
prevent tlie necessity of scratching, which young subjects could not resist if
vermin were engendered in the head. The two compresses which are placed
in front of the ears, have the triple advantage of pushing forward the tissues,
of rendering the bandage more supportable, and of preventing the motion of
the cheeks.
Instead of slitting one of the tails of the bandage through which to pass the
other on a level with the wound, it might with propriety be crossed carefully
beneath the nose. The important point is, that no wrinkles be made, and
the pressure produced be equal and gentle. Louis cut the free extremity of
his bandage into three strips from fifteen to eighteen inches in length, and also
made three slits or button-holes nearly two feet farther, for the purpose of
producing a crossing more even and firm over the solution of continuity.
Desault, on the contrary, rolled his into a single head and fixed it by a
circular turn around the head, and when he had brought it as far as the
labial angle of one side by means of the genal compress, he drew forcibly
towards him all the soft parts of the opposite side, which otherwise would
have been liable to be forced backwards contrary to the intention of the operator.
But, notwithstanding what is said by Bichat, the ordinary bandage avoids
some of the disadvantages and preserves all the simplicity of Desault's.
The sling (four-tailed bandage) generally employed is a very useful
auxiliary in some cases. By opposing the separation of the jaws, it favors
the action of the suture. When it is recollected, that in a patient of Garen-
geot a burst of laughter sufliced to disunite the wound ; that a lad operated
upon by De la Faye met with the same accident, because some tobacco being
rasped near caused him to sneeze ; it may well be permitted to employ every
means of preventing motion of the mouth. By not withdrawing the needles
until the expiration of five or six days, as directed by Garengeot, after having
taken away the thread, it is to be feared that the part may be transformed
into an ulcer and the final cure retarded. If they are withdrawn the next
day or the day following, as Le Dran assures us he has done without disad-
vantage, it is almost certain that union will not be preserved. Besides,
as there has not yet been time for suppuration to be excited around them,
their extraction can never take place without difficulty. In every case,
•when we are ready to withdraw them, it is proper to anoint with butter, oil,
or cerate, the end which is to pass through the tissues, that is, the point in
needles with heads and in others the blunt extremity. They must be drawn
gently and steadily, turning them on their axis when they resist, and always
giving support with the fore-finger of one hand to the corresponding side of
Sie lip while the attempt is made to withdraw them. A little lint spread
with cerate, and lotions of vegeto-mineral water are all that the subsequent
cure of the punctures require.
i
390 NEW ELEMENTS OF
B. Complicated Hare-lip. — «. In the double hare-lip, if the palatine
vault does not partake of the deformity, two different conditions may exist.
Sometimes the two fissures are separated only by a narrow and somewhat pro-
minent tubercle, which must be included in the angle of union of the two
incisions made in simple hare-lip. Sometimes, on the contrary, this tubercle
is too large to admit of its being destroyed without disadvantage. Then,
whether it descend or do not descend to a level with the border of the lips, it
is better to cut off the two sides at the same time as the external edges of the
double division which it separates. It is then perforated with all the needles
in the first case ; but in the second with only one or two of the uppermost,
so as to fix it in the middle of the suture. This method, the most ancient of
all, is at the same time the most simple, the most prompt, and the most
certain. Yet if the middle portion be very large at its base, we may, having
first caught its apex with one needle, carry through one or two others from
each side, in a manner still followed by M. Gensoul. After the cure the
cicatrix resembles a capital Y, and represents the passage of the naso-labial
columns. The patient scarcely perceives that he has been made to undergo
two operations instead of one. He is cured in as short a time, and subse-
quent inflammation is neither greater nor less than what occurs in simple
hare-lip. Consequently, the idea held out by Louis or Heister of not operat-
ing at first but on one side and waiting its complete cicatrization before
attempting the other, although followed since by some practitioners, neither
has nor ever should have been adopted.
b. The deformity however is sometimes still more complex. TTie portion
of the maxillary bone which supports the middle button, forms in some cases
a considerable projection forwards. Thus constituted, whether coexistent or .
not with a double division of the palatine vault, the attention must be directed
to it before passing to the rest of the operation. Franco at first, D. Ludovic,
and afterwards Chopart and several of the mojderns, have proposed to remove
it after separating its soft parts with a small saw or bone-nippers, or a gouge
and mallet. Desault having remarked that this excision would leave a
vacancy behind the lip, which therefore would not find a proper point of sup-
port; that moreover there might result such a narrowing of the superior dental
arch as in the end would bring it to lock within the inferior dental arch
during mastication, of which he gives an example ; conceived the idea of
preserving the projection, and directed his efforts to force it back by applying
for two or three weeks moderate pressure on the anterior face of the tubercle
which it supports. This mode succeeded with him perfectly in several cases.
Verdier and other surgeons have since obtained from it similar advantages.
It ought consequently to be adopted in simple deviations of the teeth nearest
the median line. To extract them, as suggested by Gerard, and as most
modern operators recommend, is an extreme means, to which recourse should
not be had until after having vainly tried to restore them to their position by
pressure, or by drawing them within the mouth by means of wires fixed to the
lateral teeth. To conclude, it is rare with judicious precautions and a little
patience that we do not succeed in removing these osseous projections in
young subjects without destruction of any part. Lassus has very well
remarked, tliat if the teeth or the bone which contains them present in frotit
no asperities or sharp angles, the operation will terminate successfully. Union
OPERATIVE SURGERY. 391
having once taken place, the pressure of the lip on the parts will be sufficient
in the course of time to give them their proper place and direction. In some
cases it would be advantageous to follow the method pursued by M. Gensoul,
in the case of a young female in whom the intermaxillary projection, sur-
mounted by the incisor teeth had become almost horizontal. After dissecting
and turning back towards the nose the flap of the soft parts, and having
removed the four incisors, this surgeon seized the prominent part of the bone
with strong nippers as for the purpose of breaking it, and succeeded in giving
it a perpendicular direction; he depressed in the same manner the right
canine tooth; made raw the four borders of the double hare-lip; used the
twisted suture, and supported the whole by a bandage. The young patient,
thirteen years old, was perfectly cured. The incisive bone became consoli-
dated, as well as the canine tooth, in the new position given to it ; and its edge,
which was on a level with the molar teeth, was sufficiently solid to serve as a
point d'appui to the inferior incisors during mastication.
c. The Simple Fissure of the Maxillary Arch, or that in the shape of Y, tp
remedy which the old surgeons thought nothing should be attempted, and
which therefore prevented them from conceiving the treatment of the hare-
lip with which it is complicated, is no obstacle to the success of the operation ;
and in this regard, unless there is too wide a separation, does not require any
special modification of the process. After the suture, its edges gradually
approximate, and finally the fissure itself sometimes completely disappears ;
insomuch, that examples are already found in Roonhuysen, Sharp, De laFaye,
Quaisnay, Richter, B. Bell, and Lapeyronie. In the case observed by Gerard,
this fissure, which was not less than a finger's breadth, was clo|ed at the end
of two years. Several weeks were sufficient in a patient of Desault; and
M. Roux mentions a child, three years old, in whom a similar separation
scarcely left a trace at the end of the fifth month. The moderate but con-
stant and regular pressure which the lip, whose continuity has just been
established, exerts upon the external surface of the bone, is the only cause of
this truly remarkable phenomenon. Nevertheless, if it is slow in effecting
it, either in consequence of the long duration of the disorder or from the
extent of the fissure, I do not see why we should not seek to favor it by
compressing bandages, applied either below the malar bone upon the skin, as
advised by Jourdain and Levret, and opposed by Richter ; or immediately
upon the alveolo -dental arches, as I myself performed in 1825, at the recom-
mendation of M. Roux ; or by covering the whole head with a bandage in the
manner of the fillet of Dent, or the tape apparatus of Terras. Indeed there
may be a thousand modes of accomplishing it ; but the object once indicated,
every one marks out for himself the course he will follow to fulfill it. As in
these various cases the part finds posteriorly but a very uneven support, and
as an artificial plate retained beneath its posterior surface would have the
serious disadvantage of irritating the parts, the bandage should be so dis-
posed as not to exercise a too powerful pressure in front. I need not add
that the needles cannot be safely withdrawn until the fourth or fifth day.
C. Age proper for the Operation. — A final question remains to be consi-
dered : is it prudent to operate on the hare-Jip during the first months of
life, or is it not much better to wait till the age of reason ? The latter opinion,
supported by Dionis and the greater part, of the surgeons of the eighteenth
592 jf *^ NEW ELEMENTS OF
century, is almost exclusively adopted among us at the present day. The
reason advanced is, that the very young infant, being incapable of concur-
ring in the precautions demanded by the operation, cries, agitates itself, and
yields to all the energy of its motions the moment it is approached. The
mere sight of the surgeon or of those around it during the cheiloraphy, is
sufficient to excite its fears and render it unquiet. The slight consistence
of the tissues and their liability to laceration, are causes why the points of
the suture tear out upon the least traction. The tongue, accustomed to the
habit of sucking, comes continually between the lips, and in some measure
prevents union. Strict diet, which is rigidly enforced for some days, pro-
duces sometimes, according to Lassus, so rapid an emaciation, that at the end
of twenty-four or forty-eight hours the cheeks of the child become flaccid,
and every part of the suture greatly relaxed. Besides, it is scarcely of
importance to the patient whether he is cured a little sooner or later, a&
long as he is unable to talk. After the first three or four years, the dif-
ficulty he meets with in expressing his thoughts, the raillery of his little
play-fellows, and the consciousness of his own infirmity, naturally create in
him a desire to be freed from this embarrassment. At this period, reasoning,
entreaties, and threats have already acquired a certain empire over him.
He is able to submit to the diet, and the density of the tissues is much
increased.
To these views Busch of Strasburg, who, with Roonhuysen, Sharp, Le
Dran, and Heister, adopted the opposite opinion, replies, that we may prevent
the motion and cries of the patient by not permitting it to sleep for several
days beforeVnd, and administering to it a preparation of opium shortly be-
fore the operation, in order that it may be quiet and fall asleep immediately
after ; that a child of three, six, or even ten years of age is often more difficult
to manage than an infant at the breast; that altogether a stranger to fear, the
latter only regards pain and real wants, whereas the former resists the idea of
the least suffering, and in reality attaches but little value to the results of the
operation which it is desired to perform on him ; and though in the infant the
tissues are more easily cut and torn, they are, on the other hand, better dis-
posed to effect prompt agglutination. I will add, that when the future is well
performed the motions necessary for the ingestion of a few drops of milk or
soup, oppose but a feeble obstacle to success. Besides, the hare-lip seldoiiji
permits the little patient to accustom itself to sucking. The prolonged
existence of the evil entails more disadvantages than seem to be imagined.
It impedes the development of . the intellectual faculties by the difficulty it
produces in the pronunciation; and consequently in the use of the ordinary
means of education. When i;t is complicated with the palatine division, the
longer we wait the more the boileS separate for want of resistance from without.
In this last case suction and deglutition itself may be rendered extremely
difficult, and death from inanition become inevitable ; examples of which have
actually occurred. Besides, tp the arguments of Lassus, Sabatier, M. Roux,
&c., we may oppose the daily practice 6f ^English surgeons ; the success obtained
by Muys,.Roonhuysen, Le Dran, Bell, and Busch, on infants, even a few days,
a few weeks, or a few month3 old ; and the three cases recently published by
M. Delmas of Montpellier. For the rest, I would operate in the first months
and as soon after birth as possible, unless I intended to w^it the expiration of
OPERATIVE SURGERV. 393
early infancy. From the period of the second year the patient being more
unmanageable is yet not much more reasonable, and the disadvantages of his
situation, which are no longer of a nature to jeopard his existence, permit us
to temporize for three or four years longer. Therefore I would select the first
six months of life, or from the fifth to the tenth year, to perform the suture of
the lips : that is, I would advise that patients who have not been operated
upon in the first period should wait until the second. After all, if the borders
of the division are so widely separated as to render it almost impossible to
bring them in contact, it would without doubt be useless to attempt tlie suture.
I saw it tried without success in 1822, at the hospital St. Louis, by M. J.
Cloquet upon an infant about a month old, under these circumstances. But
it is doubtful whether at a later period we might not succeed better. Why
not begin in difficult cases by diminishing the opening with a good compress-
or, such as the spring, from which M. Pointe, of Lyons, and subsequently
M. Maunoir, of Geneva, have found so much advantage? Why not separate
from the bone the two divisions of the lip as far as the os malae, so as to be enabled
to bring them more easily towards each other ; as appears to have been already-
advised by J. Fabricius, Horn, Nuck, Roonhuysen, &c. ? i
In whatever manner he intends to operate, the surgeon ought, before taking
the instrument in his hand, to be deeply penetrated with the idea that, notwith-
standing all its simplicity, the operation on the hare-lip requires skill and
dexterity ; that if he does not ever appreciate these according to their true
value, he necessarily performs it badly, and in proportion to the honor it does
him when he derives from it all possible success, so will it injure him when he
succeeds but imperfectly. *
§ 2* Excision.
Cancerous tumors and all cancerous degenerations are not more sus-
ceptible of cure upon the lips than elsewhere. Extirpation, when practicable,
is almost the only remedy. It is doubtful whether caustics, still successfully
employed it is said by M. Fleury of Clermont, Helmont, &c., may be
substituted in its place. In another article it was my duty to point out the
course to be pursued when the maxillary bone itself is affected ; consequently
I intend to speak here only of what concerns the soft parts. When the
disease occupies but a small extent of the labial border, or when it runs more
vertically than horizontally, the operation, as simple as it is easy, may be
performed in two ways:
1st. The first consists in circumscribing the cancer by two oblique inci-
sions within a triangular flap, a kind of V, of which ihe base shall correspond
with the free border of the lip. The patient and assistant are placed as for
the hare-lip. The surgeon seizes the morbid tubercle with the thumb and
fore-finger of one hand, while with a pair of scissors or a bistoury in the other
he describes his flap, taking care to cut in the sound parts, and to proceed
from the buccal opening towards the point of the V, which he is to take away.
The excision made, it only remains for him to bring together the edges of the
wound which hereby results, to preserve it united by means of the suture, and
to treat it as that of the hare-lip. This method, the only one followed for a
long time, is as applicable to the superior as to the inferior lip, to the middle
50
394 NEW ELEMENTS OF
portion as to the angles of the buccal opening, and is to be preferred as long
as the loss of substance need not be considerable: for example, need not com-
prise more than the half of one of the lips.
2d. The other is apparently still more simple. It is reduced to a simple
crescentic incision, including in its concavity all the unsound tissues ; which
is performed either with the bistoury, or with scissors curved in the flat ; and
which leaves behind it a furrow of greater or less depth. It is applicable only
to the inferior lip, and when the aifection extends more vertically than trans-
versely. Some moderns have without cause claimed this idea. It was in
application at the time of Le Dran. Louis quotes a patient who submitted to
it, in whom it was said the lip was renewed. Camper gives it as his own
contrivance. It is even found in Fabricius ab Aquapendente, who remarks
very justly that a large portion of the lip may thus be removed while the
deformity resulting from it is much less than mjght have been imagined.
Whatever may be the case, it was almost entirely forgotten when Messrs.
Richerand and Dupuytren raised it to consideration amongst us. Two cir-
cumstances concur in rendering easy the elevation of the lip towards the
dental arch after the excision performed in this manner. These are the
eccentric repulsion of the sound tissues caused by the development of the
cancer, and the gradual tractions excited afterwards by the cicatrix upon the
integuments of the chin or of the superior part of the neck. The fact is, that
the surrounding soft parts in subjects who have thus lost the whole lip from
one commissure to the other, have been seen to lift themselves up and con-
verge sufficiently towards the mouth to cover the roots of the teeth, and even
still higher. In the most happy cases the mucous membrane of the gums
unites with the corresponding part of the wound, and yielding to the cutaneous
cushion which tends to draw it outwards, is reflected forwards so as to furnish
to the margin of the new lip the rosy pellicle which constitutes its natural
character. In the least fortunate circumstances, on the contrary, a consider-
able portion of the jaw remains uncovered; speech is rendered incomplete;
the patient continually letting fall his saliva, is obliged to wear a metallic
instrument on his chin furnished with sponge. But happily at the present
day there exist other means of obviating this inconvenience. (See Chei-
loplasm.)
§ 3. Eversion — Mucous Enlargements,
BosselureSy a species of reddish prominence which many subjects have on
the internal surface of the free border of the lips, is a deformity to which as
yet surgery has been but little attracted. It is sometimes observed on the
superior lip, sometimes on the inferior, and at times on both at once ; in some
cases under the form of one or several tubucles, scarcely visible; at other times
with the aspect of a transverse eminence, which forces the lip out upon the
skin whenever the patient laughs or speaks. It is commonly a congenital
blemish, which rarely disappears of itself, and which is sometimes manifested
accidentally, particularly in persons who blow the horn or who are obliged
to make loud cries. Its presence is not dangerous, and is accompanied with
no other inconvenience than of rendering the countenance less agreeable. , So
the greater part of those who are affected by it carry it during life, without
OPERATIVE SURGERY. 395
thinking of getting freed from it. However, it is very inconvenient to certain
classes ; huntsmen, musicians, and orators for example. Witness two patients
operated upon in 1829, by Messrs. Roux and Boyer. Its cure is extremely
easy. Excision is performed with curved scissors or the ordinary bistoury.
While an assistant stretches the lip by its two angles and brings in view its
internal surface, the surgeon seizes ^he projection as extensively as possible
with good forceps held in his left hand, as in excision of the superfluous
portion of the conjunctiva in ectropion, and attempts to remove it entire ;
leaving in its place a regular wound which requires no dressing, and which in
general cicatrizes very readily. Numerous facts found in different authors,
or gathered from the lectures of M. Dupuytren, prove that at the end of a
week or two the cure is complete and the deformity entirely gone.
There is no doubt that the same operation would be applicable to eversion
of the lips produced by sJfy other cause, contractions or old cicatrices for
example, since this state of the mouth bears the greatest analogy to ectropion
or eversion of the eye-lid, and is remediable by the same surgical means.
§ 4. Hypertrophy.
The enlargement of the upper lip, almost natural in scrofulous habits, may
be carried so far as to constitute a grave malady, or at least a very troublesome
deformity. In some cases the whole of the organ acquires such a develop-
ment, that its posterior face looks downwards and its free border directly
forwards. While any morbid action exists; while the hypertrophy is not
decidedly fixed and reduced to the state of a simple vice of conformation, we
should confine ourselves to appropriate medicines, internal or external,
general or topical. But when every resource pointed out by sound reason has
been vainly employed, and when the affection is purely local, nothing but cut-
ting instruments can triumph over it, unless the use of compression and caustics
be thought preferable. The operation by which the patient is freed from it was
first used in 1826, by M. Paillard, who has performed it three times with
complete success, and who cites three other cases of success obtained
by MM. Marjolin and Belmas. It consists in raising the lining of the lip,
and reducing it to its natural thickness by excising a sufiicient portion of
its tissue.
The assistant, who keeps the head of the patient pressed against his breast,
is also charged with stretching the lip and making it project, by taking hold
of the left commissure with the fore-finger and thumb of the corresponding
hand. Placed in front and a little to the right, the operator seizes the other
commissure then with the right hand ; armed with a good bistoury, he makes
an incision from one labial angle to the other, and perpendicularly upon the
margin of the diseased lip, and a little nearer the mucous membrane at its
extremities than in its centre ; thus having circumscribed all which he intends
to bring away, he seizes the flap with the forceps and dissects it rapidly with
the same bistoury from the free margin to the adherent edge, and from the
left to the right extremity of the organ as far as the sound tissues, endeavoring
to give it all necessary breadth and thickness, and taking care to bring
it gradually nearer the raucous covering before terminating its excision near
the alveolo -labial fossa with a last stroke of the bistoury, or with good
396 NEW ELEMENTS OF
scissors. The wound sometimes bleeds profusely, although in general it
readily heals. No dressing is necessary. The wounded surface being con-
tinually lubricated by the saliva is soon cleansed. In cicatrizing it reacts upon
the integuments; gradually draws them forwards ; even tends to incline them
downwards, and in case of complete cure the lip not only is restored to the
thickness, but even to the direction of its normal condition.
§ 5. Cheiloplasm.
The art of restoring or reconstructing mutilated or destroyed lips, has made
in our days the most astonishing progress. But a short time since, a loss of
substance considerable enough to render simple cheiloraphy useless, seemed
to be beyond the resources of surgery. Now, on the contrary, the most
hideous deformities do not restrain the skillful operator. If a lip be wanting
on either side, in whole or in part, alone or with a portion of the cheek, it is
almost always possible to reproduce it by borrowing from the neighboring
parts the tissues which are necessary. For the rest, the surgeon must
invent rather than learn the art of cheiloplasm. It is an operation which can
scarcely be confined to detailed rules, and which must be modified almost as
often as performed. All the modes of rhinoplasm have been applied to it.
Tagliacozzi is said to have succeeded by the Itatian method ; that is, by
borrowing from the arm the materials for the new lip. Delpech, Lallemand,
Dupuytren, Dieffenbach, and Textor have tried the Indian method, which con-
sists in taking a tegumentary flap from the neighboring parts, and after invert-
ing and twisting it, fixing it in the place of the destroyed tissues. In fine,
the French method, as it is styled by M, Romand in the thesis which he
defended on this subject in 1830, a method characterized by the dissection
and separation of the internal surface and the stretching the musculo-cuta-
neous cushion which borders on the opening to be supplied, reckons already
a great number of trials. All, even to the ancient method of Celsus, in which
incisions whether vertical or horizontal, external or internal, were performed
beyond the deformity, have found defenders. Its object being to remedy lesions
of form and of different natures, it was to be presumed that each of these
methods would soon comprise several distinct processes.
Manual — 1. Ancient Process. — If there exist but a hollow in either lip,
although very deep, provided that its transverse extent be not too consider-
able, cheiloplasm differs but very little from the operation for the hare-lip.
The first thing necessary is to convert the abnormal deficiency into a recent
wound, and give it the form of a V, by paring off its edges and all the diseased
portion with the scissors or bistoury. In the second place, the surgeon
dissects one after the other the two flaps of soft parts, separates them
from the maxillary bone, turns them outwards to beyond the point of the
bleeding triangle, and to ah extent proportioned to the void to be filled.
Nothing then is easier than to stretch them, the one towards the other, and
to bring them in contact. In other respects the suture is effected as for the
hare-lip, and with the same precautions ; the posterior surface of the new lip
unites with the subjacent parts at the same time that its two halves become
mutually agglutinated ; and after the cure its free margin differs in reality
from what it was before the disease but by being a little diminished in length.
OPERATIVE glJRGERY. S97
Nevertheless this process has the disadvantage of contracting the mouth con-
siderably, and of sometimes deforming its aperture quite disagreeably. Celsus
very probably had in view something analagous, when he advised to practice
a, transverse incision, then a crescentic one between the malar bone and the
commissure on the internal surface of each cheek, in order to permit the elon-
gation of the two halves of the divided lip. There is every reason to think
at least that this kind of cheiloplasm was already thought of, of which Galen and
Paulus asgineta also make some mention.
2. Chopart'S Process. — The preceding method may suffice when the defi-
ciency of substance is not of great breadth ; but in other cases it must be
rejected, and preference be given to one of the processes which remain to be
described. That which according to Carpue, seems to have been designed by
Chopart, and which I have seen fully succeed with two subjects operated on
by M. Roux, is one of the most valuable. If there is cancer, the surgeon
commences by making on each side of the disease and beyond its limits, an
incision which descends vertically from the free border of the lip to a point
below the jaw ; he then dissects the quadrangular flap traced by these two
wounds ; detaches it from the bone, proceeding from above downwards, pre-
serving to it all possible thickness without cutting too near the periosteum ;
prolongs it below the chin or towards the thyroid cartilage in proportion to
the extent of the diseased parts to be destroyed. This done, he cuts trans-
versely and squarely all the diseased portion, encroaching a little upon the
sound tissues, and thus takes off with a single stroke the whole of the cancer ;
then taking the flap which he has just formed, carries it up and adjusts it upon
the chin, and by gentle pulling easily brings its superior margin upon a level:
with the upper lip, or the remains of the lower : unites it by means of three or
four points of the twisted suture on each side to the lateral portions of the
face, beginning always with the superior needle ; the patient is advised to
keep his head bent forwards for some days after the operation to prevent all
dragging and laceration of the parts. One must witness it to conceive with
what facility these flaps stretch and yield. In one of the cases in which I
was assistant to M. Roux, the operator being obliged to remove the whole
thickness of the lip beyond the limits of the orbicularis muscle, extended his
flap to about the middle of the subhyoid region. Yet nothing was easier than
to bring up its edge to a level with the point primitively occupied by the lip.
In four days union appeared to be effected. All the needles were brought
away. No suppuration supervened, either in its lateral edges or on the pos-
terior face of the flap, and its superior margin soon became invested with a
reddish pellicle, in a great measure resembling that which naturally lines the
buccal opening ; so that on the fifteenth day the patient, who was forty-eight
years old, exhibited scarcely any trace of the operation. The second subject
was not less fortunate, and I have not learned that any thing unpleasant has
since occurred to either. This new lip, nevertheless, having no constrictor
muscle, usually remains immovable, fixed against the teeth, and as it were
retained from behind ; but such slight inconveniences cannot enter into com-
parison with those induced by the necessity of wearing a silver lip, and
patients are too fortunate to be rid of it at this price.
3. Process of M. Roux, of St. Maximin. — M. Roux, of St. Maximin, has
several times practised cheiloplasm by a process peculiar to himself, and from
S98 NEW ELEMENTS OF
which he has obtained remarkable results. Instead of forming a flap to be
brought up after excision of the diseased part, this practitioner begins by cir-
cumscribing with incisions suitably directed, all which is necessary to destroy
in removing the cancer. Then by a careful dissection, he detaches from the
maxillary bone and the anterior region of the neck the surrounding soft parts,
and thus forms from the skin and cellular tissue a kind of apron, which he
brings up to a level with the superior lip and fixes it in front of the jaw either
with adhesive stiips, or when it is necessary previously to prolong the com-
missures by a transverse incision, unites and suspends it by some points of
suture on each side to the superior edges of the wound. The patient, the
assistants, and the surgeon are placed as in the operation for the hare-lip. If
the disease extends beyond the transverse boundaries of the inferior lip, M.
Roux makes with the scissors a first incision, crescent shaped, an inch or more
long, which extends in the same degree each commissure, prolonging them
towards the masseters ; he performs another on each side with the bistoury,
beginning at the external extremity of the former, and bringing them below
the cancer, unites them on the chin ; removes all the degenerated portions,
and in some cases lays bare the whole body of the jaw ; dissects what
remains of the cheeks by their internal surface ; returns to the chin ; descends
to the submaxillary margin as far as the subhyoid region ; preserves as much
thickness as possible to the integuments lined with cellular tissue, which he
insulates ; bringing them upwards, he attaches their extremities to the raw
prolongation of the commissures so as to preserve entirely free a sufficient
length to represent the margin of the inferior lip, and supports the whole with
strips of diachylon, a sling, and retaining bandage. When, on the other
hand, one side of the lip is untouched, and the organic change is prolonged for
some distance on the cheek of the opposite side, it suffices to extirpate the
cancer with three incisions. The one a little curved, transverse, and above
the diseased commissure ; the second, whether straight or curved is of little
consequence, equal in length to the first and continuous with it, descending
4)bliquely in front towards the chin ; the third beginning near the sound com-
missure, and terminating by union with the second. This after the dissection
is brought towards the first, and the suture is to keep them in contact. By
this proceeding the last ascends to the place of the free margin of the
destroyed lip, which it nearly represents, and the form of the mouth is pre-
served.
4. Process of Professor Roux, — In the case of a girl in whom there
remained but a very small portion of the inferior lip, and who had also lost
since infancy more than half of the superior lip, the maxillary bones had so
deviated outwards as to make a considerable projection through the opening.
To remedy this horrible deformity, M. Roux, of La Charite, determined to
perform the operation at two different times, and executed it in the following
manner : after havins: transformed the inferior half of the wound into a tri-
angle by excision of its borders, he had recourse to the saw to remove about
an inch of the jaw, and diminish its contour or prominence ; then approxi-
mating its two portions he easily brought together the flaps of the recent
wound, kept them united by the twisted suture, and thus succeeded in restor-
ing the inferior Up, and curing more than half of the diseased cheek without
much difficulty. The success of this first step was complete ; but M. Roux,>
OPERATIVE SURGERY. S99
who wished to act in the same manner for the second, and remove also
a portion of the superior jaw, found an insurmountable obstacle in the opposi-
tion of the patient, who was satisfied with this first amelioration of her
copdition. It is very evident, however, that the osseous excision here would
have presented much more difficulty than below ; and that to effect it it would
have been necessary to use the mallet and chisel, or cutting-nippers, in lieu
of the saw. By excision of the bone, the surgeon hoped sufficiently to
diminish the transverse dimensions of the face, to render practicable the
coaptation of the opposite points of the wound. Supposing it could have been
attained without it, it is probable that the cicatrix, if it would have formed,
being acted upon by the hard parts, would be afterwards toni, or at least
there would have remained a very ugly prominence on the corresponding side
of the countenance. Apart from this double complication, the method of
M. Roux, of St. Maximin, would in my opinion merit the preference.
5. Modification of M. Lisfranc. — In October 1829, M. Lisfranc had to
treat an old man whose inferior lip was entirely disorganized by a cancer.
A crescentic incision, with its concavity upwards, permitted him to detach
and excise all the diseased tissues. From the middle of this incision he began
another, which he conducted perpendicularly towards the hyoid bone ; dissect-
ing successively from the median line towards the sides, and from above
downwards, the two flaps thus marked out as in the T incision, he w^as
enabled to bring them up in front of the chin and use them in replacing the
lip which he had just extirpated. Several points of the twisted suture kept
them in apposition, and sufficed with the four-tailed bandage supplied with
lint, to prevent their descent to their natural place. Every thing announced
complete success, when about the fifteenth or sixteenth day the patient
suddenly died. About the same period, or a little earlier, the fourteenth
of July, Mr. Morgan pursued the same plan in London upon an old man,
who seems to have received great relief. The operation is certainly more
easy by this process than by that of M. Roux, of St. Maximin ; but it is doubt-
ful whether we can give as much regularity to the free margin of the new Up
as by the process of Chopart. For the rest it is a modification which may
have its value, and which enters in part into the first method I have pointed
out. The fundamental point is the dissection of the tissues which envelope
the bones of the face within the compass of the wound. All the rest belongs
to the several variations caused by the kind of lesion to be destroyed. It is
the part of the surgeon to multiply or diminish the number of incisions ; to
determine their form, direction, and depth, every time he is called upon
to employ them. The advantages of this method, the origin of which extends
back to Frabricius ab Aquapendente, particularly to Franco; which M.
Roland, of Toulouse, practised once with success; which M. Blandin has
also tried ; which I myself tested in 1830, at the hospital St. Antoine, and
afterwards at La Pitie in 1831, after the removal of the inferior maxillary
bone, and which has very well succeeded in a patient operated upon in Octo-
ber last, by M. Lisfranc, are incontestible. The two fruitless essays of M.
Delpech prove that the Indian method holds only a second rank, and that
only when the loss of substance is too deep or of too great extent to admit of
remedy by the extension of the tissues. The method of Celsus, or of M. Dief-
fenbach, is in reality but a simple variety of it, good to be called in a*
400 NEW ELEMENTS OF
accessary in some particular cases. As to the Italian method, it no loii^W
belongs to the restoration of the lips, but to rhinoplasm. The following article
will bring us to appreciate better the value of these remarks ; —
§ 6. Genoplasm,
The cheeks are also susceptible of being more or less completely recon-
structed. A loss of substance in them almost always includes at the same
time a portion of the lips, and renders the countenance truly hideous. Thus
for twenty years no effort has been left untried to remedy it. M. Delpech and
M. Lallemand seem to be the first among the moderns who have given
it attention.
1. Indian Method. — A young girl, ten years of age, had on the inferior part
of the left cheek a wound followed by gangrene, irregularly circular, twa
inches in diameter, including nearly half an inch of the inferior lip, and a few
lines only of the superior. To close this vacancy, M. Lallemand began
making raw the whole of its circumference, giving it the form of an ellipse, of
a little more curvature above than below, and of which the external extremity
of the great diameter fell between the masseter and the depressor anguli oris^
while the other ran above and without the prominence of the chin. He then
proceeded to cut upon the side of the neck, below the maxillary angle and in
front of the sterno-mastoid muscle, a flap of the same shape but fully a third
larger, dissecting it carefully and giving it all possible thickness, taking care
not to wound the external jugular vein and the ascending branches of
the cervical plexus. This flap, oblique from above downwards, and from
^behind forwards, being no longer connected with the living parts but by
a kind of root about an inch wide, the superior edge of which formed a part
of the wound, was conducted gradually and without twisting by a movement
of its whole body from below upwards into the latter, where the operator
fixed it by different points of interrupted suture, plaster strips, compresses
of charpie, and several turns of a bandage. The elliptic form was preferred for
the purpose of facilitating the union of the wound in the neck, and twisting
was avoided, because the surgeon was apprehensive lest gangrene should
be determined to the borrowed parts, as M. Delpech experienced in a
case where he had to obtain the integuments beneath the jaw, and brought
them up by doubling them in front of the chin. M. Lallemand's operation
succeeded only after many accidents. The wound was torn open several
times in consequence of the cries and indocility of the child, and more per-
haps from the presence of a canine tooth which had deviated outwards,
and which it became necessary to extract. The cure was however at length
completed. Mr. Texor, who practiced according to the Indian method in
1827, obtained from it he says perfect success. All the needles were with-
drawn on the seventh day, and cicatrization was complete on the twenty-
seventh. Since then M. Dupuytren has made an attempt of a similar kind
after the principles of M. Lallemand, and in a case much more complicated.
His operation belongs both to cheiloplasm and genoplasm. . The patient was
a child, of nine years of age, who in consequence of gangrene had lost the
left half of the inferior maxillary bone, as well as the corresponding part of
the cheek below the labial commissure, and to within three lines of the
OPERATIVE SURGERY. 401
masseter muscle. The operation was performed in the month of August 1829.
The flap was taken from before the sterno -mastoid muscle, twisted upon itself,
and fixed to the freshened edges of the wound by five points of suture. The
anterior needle first, and afterwards that which formed the connection below,
cut through the tissues and became detached. Its inferior edge only became
gangrenous and suppurated. An opening an inch in length, having its base at
the free edge of the lip, was the consequence. In every other part union took
place. To remove this new opening M. Dupuytren treated it as a simple
hare-lip, but the tongue which had contracted unnatural adhesions on this side
was an obstacle to the final success of an agglutination, which at first seemed
to have perfectly succeeded. The fact at least proves that torsion, so much
feared by M. Lallemand, does not necessarily induce mortification of the
flap which is subjected to it, and that in strictness we may go to the neck for
the integuments necessary to fill up wounds on the cheek attended with loss
of substance.
2. French Method, — a. Process of M. Roux, of St. Maocimin. — In a case
similar to that of M. Lallemand, M. Roux, of St. Maximin, followed another
mode. The cancer had destroyed the left cheek, including part of the lips,
and produced at this place an ulcer measuring two inches perpendicularly,
and one and a half transversely. By means of two crescentic incisions,
which, beginning at the lips, were united in front of the masseter muscle, the
surgeon made an incision of the carcinoma, and obtained instead a fresh ellip-
tic wound a little more extended in breadth than in height, so that he might be
able to approximate its borders ; he then dissected away at first all the inferior
lip, nearly to the right masseter and beneath the chin ; he performed the same
on the left cheek, and the curved borders of the solution of continuity were
afterwards easily brought to face each other. The twisted suture, adhesive
strips, and the retaining bandage applied as usual, prevented all subsequent
displacement, and the cure took place in a very short time.
b. Process of M. Gensoul. — A woman about 'fifty years of age, had had
gangrene of the left cheek in her ninth year ; admitted to the hospital of
Lyons in June 1829, she exhibited on the left side of the mouth an enormous
loss of substance, which left exposed a great part of both jaws, the two lateral
incisors, the two canine, and the first three molar teeth of this side all consi-
derably deviating outwards. The circumference of the ulcer which had been
long cicatrized adhered intimately to the bone, and had produced anchylosis
of the inferior maxilla. After separating it from the bone and making it raw,
M. Gensoul detached the rest of the cheek as well as the corresponding ex-
tremity of the lips, above, below, and then behind, from the adjacent tissues,
as far as the neck on one side and upon the masseter on the other ; he then
had recourse to the mallet and chisel to remove the projection of the promi-
nent maxilla, as well as the teeth implanted in it. He was then able to approxi-
mate the two edges of the wound and perform the suture. A small salivary
fistula is all that now remains of so vast a disorganization.
c. Process of Professor Roux. — The following is a case which I witnessed^
and which, though to be confounded with the preceding cases, yet diff*ers in
some points of view: — a young woman twenty years old, endowed with
indomitable fortitude and uncommon docility, had two years previously the
ala of the nose, the half of the superior lip, and all the cheek situated above
51
402 NEW ELEMENTS OF
the horizontal line of the mouth, destroyed by gangrene. There was also
necrosis of a portion of the maxillary bone, from which resulted a communi-
cation of the sore with the nasal fossas and the maxillary sinus ; and the
tongue was continually thrust from the mouth. Having entered La Charite
in the summer of 1826, M. Roux yielded to her urgent entreaties and under-
took her cure. To accomplish it he performed seven different operations,
which occupied a whole year. The first attempt permitted him to insulate
the left side of the inferior lip, and displace it by carrying it upwards to serve for
renewing the destroyed portion of the superior. Every thing in this operation
succeeded to the wish of the operator. The buccal opening was thereby com-
pletely separated from the sore, which was reduced to a large circular ulcer,
which M. Roux tried in vain to close by paring its edges and bringing them
together with the suture. A flap detached from the posterior face of the lip
by separating the lining membrane and inverting it upwards, succeeded no
better. It was the same with an attempt to accomplish it by integuments
from the palm of the hand. He took the course of bringing upwards and
outwards, to unite it with the ala of the nose and the corresponding half of the
sore, the flap which the superior lip had borrowed from the one beneath. A
triangular opening as in the hare-lip, and of considerable size at the left
commissure of the mouth, was the result of this new displacement. The
surgeon did not hesitate a short time after to pare the edges ; they were easily
adapted, the suture was performed, and this was the least troublesome of all
his efforts. At present, three years after the cure, there remain in this patient
no traces of her ancient deformity except a slight contraction of mouth, and
on the cheek some marks such as follow a burn.
All these modes of performing genoplasm having been devised for as many
individual and dissimilar cases, it would be superfluous to compare them in
order to point out their differences. The able surgeon must see which is
most proper for the case before him. It is much the same in cheiloplasm ;
consequently I have thought proper to leave the decision to the sagacity of
the reader. Franco had conceived the idea of this operation, and his observa-
tion demonstrates beyond doubt that he understood cheiloplasm, and especially
genoplasm, almost as well as modern operators. ** A James Janot," says he,
•' had a defluxion which fell in his cheek, and destroyed the said cheek or the
greater part of it, and likewise the mandibles, from which he lost several
teeth, and there remained a hole through which you might put a goose's
egg. To come to the cure, I took a little razor and cut the edge or skin
all around. Afterwards I divided the skin opposite the ear, and towards
the eye, and towards the inferior mandible ; then I cut within lengthwise and
crosswise to lengthen the lips, taking care always not to come through, for
the skin was not to be cut. I immediately applied seven wound needles, of
which, at the end of four or five days, three fell out, which had to be re-
placed by others. In short he was cured within fourteen days." But the
simple narration of this long history should be read in the author himself.
§ 7. Abnormal Coarctations,
In consequence of tetters, burns, ulcerations, &c., the anterior orifice of
the mouth is sometimes so contracted as to disfigure the patient and interfere
OPERATIVE SURGERY. 403
with the functions of this cavity. At the sight of such an evil, the first re-
source that presents itself to the mind is mechanical dilatation. Unfortu-
nately this only succeeds temporarily, and perhaps never has procured perma-
nent relief. After dilatation comes incision of the commissures, which we
should be careful to extend a little further than we wish the mouth to open,
as in cicatrizing the wound will always contract. If it were easy to cause
the two edges of the solution of continuity to cicatrize separately this opera-
tion would perfectly attain the end proposed ; but this is not the case. Not-
withstanding the cloths spread with cerate, the leaf of lead interposed, and
the little hooks by which continual traction is exercised upon the angles of
the wound, it still most frequently ends in becoming agglutinated and restor-
ing things to their previous condition if the deformity itself be not even
aggravated. Some practitioners have thought to surmount this obstacle by
treating coarctation of the lips with a leaden wire. A trocar carried through
from the skin towards the mouth makes a passage for the wire, the buccal
extremity of which being brought back through the natural opening, is to be
united with the other, so that the surgeon may twist them as m fistula in ano,
and insensibly cut through the interposed tissues. This process, less start-
ling to patients although much longer than the preceding, is however not more
certain. In proportion as the wire cuts through the parts they reunite beyond
it, so that in the end the ligature is not more eificacious than incision.
Excision, — Aware of these obstacles and the insufficiency of known means,
M. DieiFenbach supposed that by excising a portion of the thickness of each
labial angle, to the extent of an inch for example, leaving the mucous mem-
brane wholly untouched, a complete success might be obtained. Facts have
justified his theory, and already he reckons several instances which leave
nothing further to be desired. His process, more easy to comprehend than
to execute, is however within the reach of all. The surgeon inti'oduces the
extremity of a finger in the mouth of the patient, to support and protect the
organic cushion which he intends to preserve. With the other hand he car-
ries one blade of the scissors upon the edge of the coarcted opening a little
above the commissure, and enters it with precaution from before backwards
between the mucous membrane and the other tissues, until on a level with the
point where he wishes to place the corresponding angle of the lips, and cuts
at a single stroke and squarely all that is included between the blades of the
instrument; he then makes a second incision a little lower down, parallel
and similar to the first, pursuing the same course with the inferior lip as with
the upper; he then unites them, and by a small crescentic section at their
posterior extremity, insulates the strip thus formed and cuts it off, always
without touching the mucous membrane, which he detaches afterwards all
round the loss of substance; the same is performed on the opposite side; he
then gently separates the jaws so as to stretch the portion forming the floor of
the wound, and divides into two equal portions this membranous layer
until within three lines of its genal extremity ; brings it outwards and reflects
it first upon the labial commissure which he has just established, then upon
the inferior edge, and lastly on the superior edge of the division ; fixes it there
as well as to the red pellicle of each margin of the lips, by a sufficient number
of fine short needles, or the twisted suture, alone or combined with the inter-
rupted suture ; and employs it, in fine, as a kind of border, and unites it to the
404 NEW ELEMENTS OF
integuments in a sort of hem, in the manner that a shoemaker unites to the
leather of his shoes the last binding which is to cover their edges. If the
mucous layer, which need not be made very thin, be well stretched and well
fastened upon the bleeding edges of the wound, it adheres with the greatest
facility in the course of a few days. The artificial portion of the lips having
in consequence been brought to the same state of organization as the natural
portion, their adhesion is no more to be apprehended at the sides than towards
the middle. Nothing is more ingenious than this process, and it bids fair to
be generally adopted. Applicable to every shade and degree of the disease,
whether acquired or congenital, and to all ages, its only difficulty is its deli-
cacy of execution. It ought, therefore, be always attempted when the
coarctation is not surrounded by too great an alteration in the internal mem-
brane of the lips.
Art, 2. — Salivary Apparatus,
§ 1. Fistulss,
A. Of the Parotid Gland or its Excretory Ducts. — No means have been
left untried in the cure of salivary fistulas, and it must be admitted that nearly
all have met with some share of success.
1. Cauterization, whether with hot iron or chemical substances, employed
successfully by Galen on a patient in whom the fistula, caused by critical
inflammation of the gland, was situated' beneath the ear; by Pare, the two
Fabricii, Heuermann, M. Boyer, Langenbeck, and a host of others, succeeded
very well in fistulas of the gland itself; that is, in those which took their origin
from some of the radicles, and not from the principal trunk of the excretory
salivary canals. Galen used catheteric plasters ; Pare, aqua fortis ; Diemer-
broeck and Jourdain, actual cautery; M. Higginbottom, sulphuric acid; and
M. Boyer, the nitrate of silver. The lapis infernalis deserves the preference,
both because it is more convenient and because it produces an eschar drier and
more adherent than any other. However, if the ulceration be deep and nar-
row, a troche of minium may be substituted for the nitrate of silver, as I tried
with success in November, 1831, at La Pitie, on a man who had a parotid
fistula in consequence of the opening of an abscess behind the maxillary
limits. Styptics and astringents, equally lauded by some practitioners and
among the rest by Becket, being less efficacious than caustics, have been long
since abandoned.
2. Compression, used with success by Beaupre, Le Dran, and Ruffin, who
invented a machine for the purpose ; extolled also by Imbert, Jourdain, and
Richter, is nearly always sufficient when it can be borne by the patient, and
when the state of the parts permits its employment. For this end charpie or
graduated compresses are applied upon the fistulous orifice ; then with a four-
tailed bandage and a halter, or turns of a bandage properly distributed, this
point is acted upon in a manner to keep in contact the parietes of the diseased
duct.
S. Irritating Injections, proposed by Louis, are intended to inflame the
fistulous opening and determine the adhesion of its sides. They may consist
of barley-water with honey, the decoction of Provence roses in red wine, and
OPERATIVE SURGERV.
|405
even of alcohol, according to the irritability of the tissues in which adhesiye
inflammation is desired. It is a remedy which holds only a third rank, be-
cause it is attended with more risk of accidents, and does not always cure.
Yet in some cases of obstinate fistula it is not to be despised.
4. If neither of these means succeed, excision may be tried by comprising
the ulcer within an elliptical incision, and uniting its sides by adhesive strips
or the twisted suture. If the disease still persist, nothing remains but to
attempt extirpation of the gland ; but this project, ascribed to Pouteau by M.
Hedelhoffer, has never I believe been put into execution. It would, indeed,
form a case in which it might be said that the remedy was worse than the dis-
ease : the more truly so, as fistulae sometimes disappear spontaneously, of
which M. Richerand gives two examples.
B. Of the Duct of Steno. — Applied to fistulae of the stenonian duct, these
various treatments, although of less efiicacy, still reckon a certain number of
undeniable cures.
1. Cauterization, for example, alone or assisted by compression, procured
for Louis an unhoped for cure upon a subject who had carried his fistula for
nineteen years, and submitted to several operations without success. Fer-
rand, Nedel, Mursinna, Imbert, Jourdain, and M. Langenbeck have been no
less successfiil.
2. Compression, without caustic, and as a single means, has on its part
appeared sufficient. Maisonneuve, who first advised it in this case, established
it between the fistula and the gland for the rational purpose of closing the
passage to the saliva, and permitting the opening to cicatrize. His patient,
who had received a sabre cut on the cheek, was radically cured at the end of
twenty days. Louis, and with him most of the moderns, have thought that by
this mode inflammation will be almost necessarily determined to the whole ex-
tent of the parotid gland, and consequently it could not fail to be dangerous.
Desault thought to dissipate these fears by directing compression upon the gland
itself, in which he proposed to induce atrophy. Whether this atrophy really
took place, as Desault affirms, or whether the parotid gland continued its
functions afterwards, as M. Boyer seems to think, it is the fact that the fis-
tula cicatrized early, and the patient had no return of it afterwards. How-
ever it may be, there are in the designs of these authors two ideas which it is
necessary not to confound ; that of Maisonneuve, who wished to suspend for a
time the flow of the saliva ; and that of Desault,who preferred to dry up its source.
Without believing with Heuermann that the parotid gland would form abscess,
ulcerate, or pass to the state of scirrhus or cancer, I cannot yet admit that
such means are harmless ; they ought, in my opinion, to be reserved for sub-
jects whom every other operation alarms or has failed to cure.
3. Ligature of the Duct, — Zang, who partakes of the opinions both of
Maisonneuve and of Desault, recurs to the process of Viborg for determining
atrophy of the parotid gland. Instead of compression, which is always un-
certain, this surgeon proposes, as the object is to prevent the passage of the
saliva, to apply a ligature to the duct of Steno beyond the fistula. Numerous
experiments upon animals towards the close of the last century convinced
him that this ligature is not dangerous, and is always successful. To apply
it, it is best to make a vertical incision about an inch long over the anterior
margin of the masseter muscle, immediately below the zygomatic arch, and
406 NEW ELEMENTS OF'
divide successively the skin, the adipose layer, and then a fibro-cellular ex-
pansion which spreads over the buccinator muscle. The duct being exposed,
is to be isolated from the other tissues, particularly the branch of the facial
nerve which runs along its superior edge. Nothing then is easier than to pass
a thread around it and obliterate it. Doubtless, if the sacrifice of the func-
tions of the parotid gland has been previously determined, the advice of Viborg
ought to be followed to the exclusion of that of Desault and of Flajani ; but
compression, having the advantage of requiring no incision, will nevertheless
be adopted in preference by timid and pusillanimous patients ; whence it fol-
lows that these two modes will have in practice each its particular appli-
cation.
4. TTie Twisted Suture, as in hare -lip, when, the anterior portion of the
canal remains free, is sufficient in many cases, according to Flajani, Percy,
Zang, &c., and most frequently renders all other means unnecessary, if
applied in good time.
5. To Re-establish the Natural Passage. — Morand first, and after him Louis,
are the two authors to whom is due the idea of dilating the duct of Steno to
cure fistula of that part. Placed in front of the patient the surgeon takes the
labial angle between the thumb, introduced within the mouth, and the first two
fingers of the left hand upon the right cheek, but with the right, if the fistula
is on the left side; stretches and turns it outwards; then introduces with the
other hand the head of a fine stylet armed with a thread, into the natural
orifice of the parotid duct ; withdraws it through the fistulous opening, where
he leaves the little seton, the two extremities of which he unites by a knot, and
which is made use of the next day to draw a cord of silk into the mouth from
the exterior to the interior; he renews this seton every day, bringing it out by
the wound, and increases its size every time by the addition of a thread. When
it is too difficult to penetrate by the mouth, Louis introduces the stylet
through the sore; it should indeed be quite indifferent whether it be introduced.
by one way or the other. In this last case, however, the thumb should take
the place of the fingers in order to straighten the canal and to incline its orifice
forwards when the stylet is about to come through ; not because it makes a bend
in passing through the buccinator, as is generally admitted from the observation
of Louis, but because it enters the mucous membrane at an acute angle, which
closes it in a great measure, and seems to throw its opening a line back-
wards.
When the saliva passes freely into the mouth and the ulcer is contracted to the
size of the seton, it is to be removed, or, what is better, cut off on a level with
the integuments, and drawn forwards about a line by its buccal extremity so as
not to be wholly withdrawn until the fistula is entirely closed by means of
repeated cauterizations and desiccative applications. If it were always easy
to find the anterior termination of the divided canal ; if this canal were not
generally long obliterated when the surgeon is called in ; if, lastly, it were
very important to preserve it, the process of Louis, exactly traced out from
the idea of Mejean in the treatment of lachrymal fistula, would certainly
have obtained general assent ; but the fact is otherwise, and the following mode
is generally adopted by operators at the present day.
6. Establishment of a New Passage. — Deroy, who, as it is said by Saviard,
seem^ to have devised this method, perforated the cheek with a hot iro^i^
OPERATIVE SURGERY. 407
thus removing a portion of matter and curing his patient. Shortly after Chesel-
den gave the same advice. Duphenix performed it in a different manner. He
made use of a long narrow bistoury, inserting it from above downwards and
from before backwards, turning it several times on its axis to make his open-
ing of a round form; he then introduced in its place a canula shaped like the
point of a pen, designed to conduct the saliva into the mouth, the external
extremity of which, concealed within the cheek, was to correspond with the
parotid opening of the fistula. The edges of the ulcer were then pared, and
in conclusion Duphenix had immediate recourse to the twisted suture. The
canula left to itself came away on the sixteenth day, and the cure was com-
pleted. According to Monro a shoemaker's awl was advantageously substi-
tuted for the cautery of Deroy and the bistoury of Duphenix. With this
instrument, of which the celebrated Edinburgh surgeon seemed to be very fond,
he traversed the cheek in the natural direction of the canal, and for a seton
used a thread passed through the wound. When the passage had become
callous he withdrew the thread, saw the saliva flow into the mouth, and then
gave his attention to the small external ulcer. Platner, a great partisan of
this mode of operating, recommends the patient to gargle with brandy in
order to hasten the induration of the internal orifice of the new duct, and at
the same time to compress the exterior of the wound, or to touch it with
nitrate of silver. After perforating the parts /. L, Petit advises to enlarge
the buccal opening by introducing within it every day a small piece of sponge,
until the fistula is closed. Tessort saw the saliva return to the mouth,
from passing a simple thread through the cheek ; the use of adhesive strips
sufficed for the ready cure of the ulcer. Flajani advises to pass a double silk
thread through the fistula by means of a needle, and in the rest to follow the
example of Monro. In a patient who could not support compression, Desault
employed a hydrocele trocar to pass the thread through the cheek ; to the internal
extremity of this thread was tied a seton, which he drew from the mouth to
the bottom of the fistula, yet in sucii a way as not to prevent cicatrization.
The seton was withdrawn, and replaced daily by one a little larger, and dis-
continued several days before the thread which held it, and when the opening
had become almost completely closed. Like Desault, Bilguer also had
recourse to the trocar; but instead of the seton he left a leaden canula within
the internal half of the wound, whicli he closed over it. Richter carried into
the mouth a piece of cork to support and receive the point of the trocar ; and
used a seton of thread, the size of which he gradually increased. He with-
drew it when the new canal was become sufficiently firm, and cauterized the
opening on the exterior, or scarified it and brought its edges together. In
more obstinate cases he introduced by the mouth into the artificial duct, and
there left to remain, a canula of gold or silver, furnished with a button to
prevent its slipping away. More recently, in 1824, M, .^^^i, intending to
improve the process called Beclard's, has rather modified that of Desault.
The canula of a small trocar served him to conduct through the cheek a tent
of lead, pierced laterally with several holes, supported by a thread from
without which kept it within the wound, and divided to the extent of about
a line from its internal extremity into three branches, which being bent
over in the mouth prevented its being drawn out bj the thread. When the
fistula is sufficiently reduced, M. Atti touches it with lapis infernalis after
408 NFW ELEMENTS OF
bringing away tne tnread, and attempts to close it entirely. The tent of
lead left Within the cheek escaping after some time into the mouth, leaves
behind a new canal which perfectly supplies the place of the original. The
successes which the author adduces in support of his ideas confirm their
correctness, and his process is without dispute at the same time one of the
most simple, the most ingenious, and the most certain that can be imagined*
It is assuredly preferable, for example, to that of Mr, Charles Bell, who, like
Flajani, passes a needle through the cheek to carry first a thread and then a
seton into the fistula, and when the internal opening is callous, attaches a hair
or very fine thread to the external extremity of this thread, and then treats it
like Desault or Bilguer.
7. In the hope of rendering the operation more prompt, and union of the
ulcer more immediate, surgeons for these thirty years have directed their
views to another course. Rejecting all species of foreign bodies, M* Lang-
enbeck proposed to dissect and insulate the posterior end of the duct of Steno ;
to make at the bottom of the fistula an opening, which would admit of its being
conducted into the mouth, and to fix it in its new relations, immediately to
unite the edges of the opening. But this professor has not as yet, to my
knowledge, found imitators, and ought not in future. M, Latta says that the
best mode of curing salivary fistulas consists in passing a string of catgut
through the cheek ; then to try to engage its external extremity in the parotid
duct, leaving the other within the mouth, and close the wound by the suture or
by plasters ; as if it were always possible to find the orifice of the Stenonian
duct at the bottom of an ulcer ! Zang, however extols this mode of proceeding
when the fistula is very large and the anterior portion of the canal obstructed,
but he advises the use of the canula of the trocar for introducing the catgut;
that this cord be sharpened to a point at the extremity which is to penetrate
the duct towards the gland, and that it should not entirely fill the artificial
canal, but permit the saliva to flow along its side. Placing the practice of
Latta and Zang upon its true ground, it is easily perceived that it differs in
reality from that of Desault and Charles Bell, only in their dispensing with
retaining their tent from without by means of a foreign body. This allows
them to close the fistula at once, and that whether they have succeeded or not
in inserting the end of the cord into the natural duct of the gland. It is then
possible to effect a cure in this manner, as by most of the processes heretofore
described ; but it has the inconvenience of not holding the seton firmly enough
within the substance of the cheek, and of permitting it to escape too soon. It
is an objection which might be equally applied to Percy, who says he has
frequently succeeded by using a leaden wire instead of the catgut employed
by the Germans. To obviate this objection M, de Guise took the following
method with a young person, whose fistula, already chronic, had resisted
various methods. A hydrocele trocar carried through the sore from without
inwards, and from before backwards, allowed him to carry through its canula
a leaden wire into the mouth. By a second puncture in the course of the
natural canal, that is, from behind forwards and always from without inwards,
he was enabled to carry the other extremity of the wire into the buccal cavity,
to bend the two portions on the internal surface of the cheek, and to unite the
external opening by the twisted suture. After several days, agglutination
seemed complete. The coil of lead, whose convexity corresponded with the
OPERATIVE SCROERY* 409.
fistula, and which embraced in its concavity the internal cushion of the cheek,
was carefulW withdrawn, and the cure was no longer doubtful. Three observ-
ations, recorded in the name ofBeclardinthe Archives, prove that this surgeon
has often imitated M. de Guise with success. Instead of leaving the two
extremities of the leaden wire loose in the mouth, he united and twisted them
together for the purpose of insensibly cutting through the interposed tissues,
as in fistula in ano. Moreover, in making the second puncture he carried
the trocar through the mouth in order that the beak of the canula might not
prevent its being withdrawn the same way after having placed the second end
of the tent, which is not possible when it is directed from the exterior to the
interior, as at first. Finding that it wks not as easy to carry the trocar through
the mouth as through the sore, and desiring to remedy the inconvenience com-
plained of by Beclard, M. Grosserio proposed a trocar fitted with a canula
deprived of its shoulder. With this modification it is quite as easily with-
drawn through the mouth in the second step of tlie operation as through the
wound in the first. In fine, M, Miraulty who has since made the same propo-
sition, thinks that a seton of thread will be better than a wire of lead, and that
with the assistance of a serre-noeud modelled on that of Desault the end would
be more easily attained than by simple torsion. Acting on the idea of M. Mirault,
M. Eoux used a seton of silk with full success. Lastly, M, Vernhes has
been equally fortunate with a gold wire passed from above downwards, and not
across as by M. de Guise, and which he used like Beclard, to cut through the
interposed substance by gradually twisting it upon itself. Perhaps also we
might confine ourselves to puncturing in some way the parotid duct posteriorly,
so as to establish an internal fistula in the salivary passage and be enabled
to close the one without. But this process,which I proposed in 1 823, has not as yet
been put to the test. Like that of M. de Guise and all its gradations, it would
only be applicable in cases where the wound of the canal is not too near the
masseter muscle. To determine the relative value of so many different pro-
cesses, it would be necessary to represent every shade of difference that may
be exhibited in salivary fistulae. In this point of view there are few which
have not their advantageous side. However, the seton after the manner of
Desault or Charles Bell, the tent of lead of M. Atti, that of Percy, of Latta
or Zang, are best in every respect, and ought to be preferred. To follow M. de
Guise or Beclard with the modification proposed by M. Grosserio, it is required
that the fistula be at some distance from the masseter muscle; in which
case it is the most certain method, and undeniably superior to all others.
C. Fistula of the Submaxillary Gland.- — If it happen, of which examples
have been deduced, that a sore or an ulcer of the subhyoid region should
extend to the submaxillary gland and remain fistulous, to effect its cure all
the means would have to be tried which have passed in review on the occa-
sion of fistulas of the parotid gland. If nothing can dry up the source of
such an evil ; if especially the secretory organ itself be altered to a great
degree, and threatened with an unfortunate degeneration, extirpation, which
Pouteau was bold enough to conceive for the parotid, would here be a laat
resource, which should not be neglected. M. Amussat has performed it
with entire satisfaction. The process to be followed in such a case will be
discussed hereafter.
' 52 ' ■ ■ . .
410^ NEW ELEMENTS OF
§ 2. JRanula or Frog^s -tongue.
History. — Ranula is a disease of little importance, and generally, accord-
ing to Boyer, not dangerous. It has more than once, however, been seen to
endanger the life of the patient, and in every case is sufficiently troublesome
to create the desire of getting rid of it. De Hilden records one which filled
I. the whole mouth; Marchetti another, which compressed the carotid arteries
and the trachea. Alix is said to have operated on one, which was on the
point of suffocating a child ; and Taillardaut on another, so voluminous as to
prevent the patient from eating. Burns relates, that a man who waited in
the study of Cline had his respiration so embarrassed by the presence of a
ranula, that he dropped down insensible after having experienced violent
convulsions. Although the ancients understood but imperfectly the nature
of this disease ; though some made it an encysted tumor, with Celsus ; though
others, with Aetius, considered it as a varicose dilatation of the sublingual
veins, or with Abul-Kasem as cancer; with Paracelsus, as an aposteme of the
vessels of the tongue ; or as an ordinary abscess with Aranzi; they neverthe-
less attempted its cure by almost all the means employed since Louis endea-
vored to prove that it is nothing more than a tumor caused by an accumulation
of saliva, either in the maxillary gland itself, converted into a cyst, or in its
excretory duct, enormously dilated. Instead of pure and limped saliva; of
inspissated saliva, of mucus, of purulent matter ; or of a viscous substance more
or less consistent, the morbid pouch is sometimes filled witlf gravel, sand, or
even true calculi. In a case reported by Tulpius, it was formed by a con-
cretion so hard as to require the employment of actual cautery to destroy it.
Schultz, E. Koenig, and V. Rieddlin cite cases of the same kind, which have
also been met with by J.L. Petit, Freeman, Sabatier, Taillardaut, Loder, and
M. Boyer. In all these observations the indication was precise. A free
incision of the tumor permitted the extraction of the foreign substances, and
the cure was speedily effected.
Indication. — Ranula, properly speaking, requires other attentions. Expe-
rience proves that evacuation of the fluid is not sufficient to prevent its
return. Incision, caustics, tents, dilatation, excision, extirpation, canulae, the
seton, &c., have each in turn had its partisans on this point.
1. Incision, which first presents itself, at once empties the tumor and seems
to have cured the disease. Besides, nature would seem to have suggested
the first idea of this, since the ranula frequently opens spontaneously. Hip-
pocrates recommended it, and performed it with a lancet. Celsus and Aetius
mention it, but do not seem to place much confidence in it; nor did Rhazes,
who was apprehensive for the vessels which the bistoury might divide at the
same time. Although somewhat bolder, Abul-Kasem did not venture to have
recourse to it, except in sublingual tumors of a light color and fluctuating,
fearful that by incising others there would be danger of their passing into a
cancerous condition ; that is to say, Abul-Kasem had been led unwittingly to
distinguish true ranula from the tumors with which in his time it was con-
founded. Instead of plunging the instrument into the cyst itself, Paracelsus
merely opened the vessels running into it, and consequently can scarcely be
considered as one of the partisans of incision of the ranula. When fluctua-
tion was perceived, Aranzi, who did not distinguish it from abscess, advise*
OPERATIVE SURGERY. 411-
it to be opened with the lancet, and P. Forrest asserts that it will not return,
if, after opening it, the surgeon takes care to press it and evacuate all the
matter. According to Bartholin, Six waited until inflammation had ceased in
the tumor, and then pierced it through and through to evacuate its contents.
Notwithstanding the reasons of V. D. Wiell and daily experience, Jourdain,
about the middle of the last century, still maintained that a large incision
with the lancet very frequently cured ranula, and that its treatment may be
confined to this. There are, indeed, some subjects who are thus finally rid
of their disease, but every one at the present day agrees that it is but a pal-
liative remedy, and that generally the salivary cyst is sure to be refilled.
2. Catheterics. — Injections. — Tents. — To preserve to the operation a part
of its ancient simplicity ; to prevent the wound from closing too rapidly ; to
obtain, in fine, a cure which incision alone was far from always obtaining,
Paracelsus kept detersive substances within the wound ; Purmann introduced
styptics into it, and was imitated with success by V. D. Wiell ; Camper
touched it with lapis infernalis, and Acrel left in it a dossil of lint steeped in
spirit of salt; Callisen advised to place in it lint alone, or to cauterize its
cavity with a mineral acid ; by which means he said the cyst would become
detached and might be brought away. A surgeon of Saltzburg, quoted by
Sprengel, found it more convenient to make injections of camphorated spirits
or oil of turpentine, and cured his patient. It was the same in the case men-
tioned by M. Haime, of Tours, which he also cured by means of injections,
thereby causing adhesion of the parietes of the cyst. Leclerc was no less
fortunate with the nitrate of mercury, and the observation of Sabatier proves
that a tent of charpie renewed or cleansed every day sufficed, after incision
of the ranula, to render the wound fistulous and the cure radical. Yet as it is
not rare for the disease to resist this combination of means, it has been devised
to destroy a part of the sac which constitutes it.
3. CaiUerization.-^-Ca.us\ics were employed from the time of Aetius.
Dionis preferred a mixture of sulphuric acid and honey ; but the hot iron has
found a greater number of partisans than escharotics, properly so called.
These latter are indeed more difficult of management, more uncertain in
their action, and almost always dangerous when carried into a part so delicate
as the mouth. Pare, who had experienced their disadvantages, conceived the
design of plunging into the tumor a kind of trocar, at a white heat, through
a metallic plate intended to protect the adjoining parts. In this way he pro-
duced a loss of substance, the wound became fistulous, and the ranula never
returned. Aquapendente carried his cautery through a barred canula. Loui's
advises much the same thing ; that is, he prefers the actual cautery to a cut-
ting instrument. He merely remarks, that by making the orifice in front we
expose the saliva to spout out and escape involuntarily from the mouth.
Nevertheless, cauterization is rather rarely employed in our day, as much
perhaps on account of the fright it gives the patient as of its not being very-
infallible. M. Larrey, who advises that the red hot iron should traverse the
tumor through its whole extent, is almost the only one who continues to accord
it the preference.
4. Excision. — In introducing the process of La Cerlata, who held the
ranula with a hook and excised it with a razor ; or that of Aquapendente, who
fieized it with forceps and cut it off with scissors, or passed around it a ligature >
412 NEW ELEMENTS OF
Tulpius, J. L. Petit, Desault, and Richter have labored to show that after the
removal of a sufficiently large flap from the cyst, the tumor is seldom
reproduced. The fact is, that Desault, in his practice at the Hotel -Dieu, has
generally succeeded in this manner, which M. Coley has so much praised, and
of which M. Boyer, who followed the same plan, has the highest opinion. It
is performed in different ways. The most simple and most certain is the
following: the jaws of the patient being separated as widely as possible, the
surgeon, armed with a straight bistoury, commences by making a crescentic
incision with its convexity external through nearly all the gingival surface of
the tumor ; he then seizes with good dissecting forceps the flap thus marked
out and detaches it with the scissors, giving it the form of an ellipse. Gene-
rally bo vessel of importance is opened. It is seldom that more than a few
drops of blood flow, or that the patient feels much pain. Dressings are
unnecessary, and the wound, which becomes smaller and smaller every day,
but usually without closing entirely, prevents the danger of relapse.
5. Extirpation. — Loder and Sabatier have, however, seen the disease resist
this treatment, and many authors have also maintained that the certain
mode is to extirpate the ranula, or destroy it entirely with caustics. A rather
obscure passage in his works leads to the opinion that Celsus himself advised
this last resource. Treating of sublingual tumors he says, when they do not
yield to puncturing we should incise the skin that covers them in order
to extract them, taking care not to wound the vessels, while an assistant sepa-
rates the lips of the wound. Mercuriali, the first author who distinctly
prescribes it, raises the tumor with a hook, cuts it at its base in the mouth,
and says if the whole of the cyst is not destroyed the disease will not fail to
be reproduced. Diemerbroeck commenced with a crucial incision, and extir-
pated it entire. Without going so far, Alix cut into it freely, but lengthwise,
and brought away with the scissors as much of the cyst as he could. In a very
serious case, Marchetti, who had introduced a seton into the mouth penetrat-
ing from the supra-hyoid region, was notwithstanding obliged to extirpate all
he could of the tumor, and destroy what remained with a hot iron. It seems
evident however that complete extirpation is seldom indispensable, at least
when the disease is not threatened with fearful degeneracy or transformed into
a solid tumor. Otherwise it is quite sufficient to excise the portion pro-
jecting into the mouth; the more so, since by then touching the bottom
of the wound plentifully with nitrate of silver, sloughing will be readily
produced.
6. j9i7a?a/ton.— Although the disease consists generally in the course of the
saliva not being free; although Louis, imitated by Leclerc, succeeded in
opening the ducts of Wharton, which appeared like two apthae on the sides of
the fraenum ; though he was able to dilate them by placing a sound within them,
and the patients thus treated were cured; yet it must be acknowledged
in accordance with Richter, that dilatation would here be the most defective
and trifling resource, and sometimes even altogether impracticable. Excision
after the manner of M. Boyer has great and indisputable advantages over it,
without being subject to the same uncertainty and the same difficulties.
7. Permanent Canula. — This has not prevented some modern operators to
decide for incision, which they have thought to render more efficacious by
combining it with the use of a canula left within the opening of the cyst. The
OPERATIVE SURGERY. 413
idea of such an association had not, I believe, been published before Sabatier.
Still this author only speaks of a canula left in the wound long enough to
render it callous. But at his time it had evidently presented itself to the
minds of some other practitioners, since he makes menti(»n of a patient who
had worn one for three years, and whom he advised to continue its use. It
was about an inch long, with a lenticular button at one of its extremities,
which prevented it from penetrating too far, and did not sensibly affect the
speech or mastication of the person who used it. This canula M. Dupuytren
has modified in an ingenious manner, by making it considerably shorter, and
terminating each extremity with a lenticular plate. After opening and
emptying the cyst, this professor engages within it one of the buttons of his
instrument, the other disk of which remains in the mouth. The tissues which
embrace the neck of the insti'ument in a short time contract so as to prevent
its derangement in any way. The saliva escapes by its canal, and the patient
wears it as long as it is deemed necessary, sometimes even during life, without
any real inconvenience. M. Dupuytren has the plates of his instrument,
which should be of gold, silver, or platina, convex on their free surface only,
and concave inwards, so that the food may not find its way between it and the
parietes of the cyst. Nothing, it is true, prevents the trial of this method,
which, according to the new editors of Sabatier, constantly succeeds at the
Hotel-Dieu. But I do not see that it has in reality a great advantage over
simple excision, which on the other hand is rarely followed with failure in the
practice of M. Boyer. It is seen from this view of the subject that the treatment
of ranula is wholly founded on that of hydrocele, as M, Haime has moreover
remarked, with Purmann, who endeavored to produce adhesive inflammation
of the salivary cyst in the way that adhesive inflammation is caused in the
tunica vaginalis. The seton itself has not been wanting in this case, and it
might be used with some probability of success, if other modes were not a
thousand times more rational. As proved by the practice of Dr. Physick, who
has long employed it, and the observations of Mr. Lloyd, who also used it in
London, and the work recently published by M. Langier, this resource is not
without a certain degree of efficacy.
§ 3. Salivary Tumors foreign to the Excretory Canal.
Tumors, apparently salivary, are sometimes seen elsewhere than at the sides
of the tongue. I attended a patient in the hospital Saint Antoine, who had
one for a long time between the lip and the left superior alveolar arch, of which
he rid himself every month by opening it with a bistoury or lancet. M. Graefe
says he has often observed it in the substance of the lips. Wilmer mentions
one which was located in the inferior maxilla ; and M. Dupuytren has often
met with them in the substance of the bone itself. The one treated by M.
Latour occupied a great portion of the cheek ; and M. Ricord has published,
under the title of " Hydatid of the Canine Fossa," a case which probably
belongs to the same species of lesion. All the above mentioned modes are
applicable to them ; but when a radical cure is to be obtained recourse must
be had to excision, either simple or aided by cauterization, or to extirpation.
A wound of the salivary ducts may also give rise to tumors of this nature,
even over the course of ^e duct of Steno. M. Verhnes, of Tarn, has recently
414 NEW ELEMENTS OP
made known an interesting example of it : in consequence of traumatic lesion
there arose on the inside of the cheek a small oblong tumor filled with saliva,
which M. Verhnes succeeded in curing bj passing through it a small trocar,
carrying with it a double gold wire which he employed as a seton. If a
similar case should present itself, the practice of this surgeon should be
imitated ; at least, if we are unwilling to simply trusc to the process of Beclard
in salivary fistulae, or rather to the treatment applicable to ranula.
Art, S.-^The Tongue.
§ 1. Tied Tongue,
The species of fibro-mucous fold which fixes the free portion of the tongue
to the posterior face of the chin, and which is called fraenum when its dimen-
sions are well proportioned, takes the name of Jilet when it is too long antero-
posteriorly, or too short perpendicularly. The child in this case finds it im-
possible to suck. • The point of the tongue being arrested against the inferior
limits of the mouth, cannot be brought without to seize the nipple. It is,
therefore, a disposition which might have serious consequences if not imme-
diately remedied. Yet we should be cautious in deciding that the child has
a. Jilet when it does not suck, or when it is slow in speaking. Such accidents,
which might be produced by a thousand causes, do not depend on the fraenum
of the tongue, if the finger when passed into the mouth can be seized by it,
and if it is possible for its point to arrive at the lips ; and it is only in the
contrary case that the division of the filet is to be thought of.
History, — Nothing indicates, unless it be an expression of Cicero, that this
trifling operation had been described before Celsus, who in performing it
lifted the tongue with forceps, and recommended caution in not cutting the
vessels. Instead of forceps, Paulus Egineta.and Abul-Kasem used a hook,
the more certainly to avoid hemorrhage. Avicenna traversed the base with a
ligature, and thus dispensed with a cutting instrument. De la Cerlata, who
blamed mid wives for tearing it away or cutting it with the nail, destroyed
it with a peculiar instrument, raising the tongue with two fingers. The
pointed scissors of Friederich are justly rejected by F. ab Aquapendente,
who inveighed against the evil custom of matrons, already condemned by De
la Cerlata. After raising the tongue, J. Fabricius seized the filet between
two fingers, and divided it with little strokes of a curved bistoury, and says
moreover that this operation is rarely indispensable. De Hilden is of the
same opinion, and performed it with a cleft instrument which served at tlie
same time as scissors and a fork to support the tongue. The blunt fork and
the large scissors invented later by Scultetus and Solingen, are useless. The
idea of dividing the filet with a red hot bistoury, as performed by Lanfranc,
would at the present day be ridiculous. The springed instrument of J. L.
Petit, praised by Platner, appeared unsuitable to Le Dran, who maintains that
blunt scissors are always sufficient, and that it is superfluous to tear the
wound with the finger to enlarge it when the incision has been made, as Dio-
nis did. The cleft spatula of Richter and Callisen, the curved and blunt
scissors invented by G. Schmitt, are not in use amongst us, although they
may yery well attain the end proposed by their aut^rs. Always ingrenious
OPERATIVE SURGERY. 415
in constructing new instruments, M. Colombat has just proposed one which
seems to me entirely useless, as well as the excision which he wishes to sub-
stitute for simple incision.
Operation. — The method of Le Dran is now followed ; that is, the child be-
ing placed with its head bent backwards against the nurse, or some other person
who will not be intimidated by its cries, the surgeon raises the tongue with
one or two fingers of the left hand, while with the other, armed with blunt
scissors, he rapidly divides its frasnum. But as the volume of the fingers
often hinders the rest of the operation, there has been generally adopted,
since J. L. Petit, a grooved sound, the plate of which being split supplies
their place, and at the same time protects the vessels. When the filet is
well engaged in the bifurcation of this plate, the operator raises its body a
little towards the forehead of the child, so as to throw the tongue backwards
and upwards ; he then introduces his scissors beneath, and with a single stroke
cuts the membrane thus stretched, taking care to direct the point of the
instrument a little downwards, to be more sure of running no risk of touching
the raninal arteries. The wound requires no attention, and it is extremely
rare that the little patient suffers from it for more than a few hours. The
motions of the organ prevent agglutination, and on this point I do not see the
necessity of touching with the nitrate of silver, as advised by M. Hervez, of
Chegoin. Tetanus, which resulted from it in the child spoken of by J.
Fabricius, who had been operated upon by a quack, has never been observed
since. According to some authors, two serious accidents, hemorrhage and
inversion of the tongue into the pharynx, may be manifested after the section
of the filet. The first happened to Roonhuysen himself, who could not
arrest the bleeding but by inserting vitriol into the bottom of the wound.
Maurain ran still greater risk ; he had to resort to the actual cautery. J. L.
Petit cites two cases in which the operation had been badly performed, the
subjects of which would evidently have died if instant relief had not been
afforded. A circumstance which aggravates the danger in this case is, that
instead of being spit out the blood is swallowed as it flows, and if not watched
the child may sink before the cause is discovered. By using the sound, and
the precaution to cut nearer the floor of the mouth than the tongue, it is almost
impossible that such hemorrhage should take place. If it does, however, it
may be arrested by applying to the bleeding point the head of a stylet heated
to whiteness; or, as practised by J. L. Petit, by means of a fork of wood an
inch long wrapped with linen, resting against the internal face of the maxil-
lary symphysis with one part and embracing with the other the apex of the
wound, while a small bandage passed across within the mouth, brought back,
then crossed below the jaw, and carried up over the ears to be fastened to the
child's cap, prevents motion of the tongue. Two small blades united in the
middle in the form of pincers, with which the bleeding part is seized, and
which is made to act by pushing a wedge between the two portions of its
other exti'emity, will accomplish the same end, and attain it with even still
more certainty. The natural softness of the tissues and the retraction of the
arteries, will in general render the ligature recommended by Courtois alto-
gether inapplicable
As to Inversion, the moderns scarcely admit its possibility. J. L. Petit,
who witnessed three examples, explains it by saying that the fraenum being
41 6 NEW ELEMENTS OF
once cut, the tongue becomes free and is turned back and directed toward*
the throat with the more facility ; as the child, which until then could not take
the breast, sucks it with a kind of voracity. In one case, this practitioner drew
it three times from the pharynx ; but at the fourth the patient died for want of
relief. J. L. Petit has seen the inversion during life, and verified its existence
after death ; it is a fact therefore undeniable. I do not see, besides, why it is
so difficult to comprehend, or why there is any question of what travellers
relate of those orientals and negroes, who, to avoid too severe chastisement,
cause their own death by swallowing their tongue. It may be prevented by
not carrying the division of the fraenum too deeply. To remedy it, we must
with the finger bring back the tongue to its natural situation, and cause the
child continually to suck while there is danger, and when it does not suck,
to keep the tongue down with the bandage just mentioned in speaking of
hemorrhage.
§ 2. Anchyloglossis.
Adhesions of the tongue to the mouth have always attracted the attention
of surgeons. Whether congenital or acquired; the result of simple inflam-
mation or produced by more extensive lesions ; whether recent or of long
standing, the knife is the only means of overcoming them. Aetius says, the
abnormal membrane or cicatrix is to be seized with a hook, and divided with
all necessary precautions. Towards the middle of the seventeenth century,
J. Hellwig, being consulted by an individual who could not articulate,
destroyed by dissection the adhesions of his tongue, and thus restored him
to speech. In our days the practice is not different ; but we must be cautious
not to be deceived by a disposition sometimes met with in infants. The tongue
is then merely pasted as it were against the palatine vault, as witnessed by
Louis, or to the floor of the mouth ; which has caused more than one gossip
to suppose that the child had no tongue. The finger, the handle of a scalpel,
or a spatula, is always sufficient to destroy this simple agglutination, which
perhaps is in reality the commencement of a true anchyloglossis. The con-
duct to be observed with adults is the same, if we are called before the adhe-
sions, resulting from extended inflammation, have acquired any considerable
firmness.
1. If there are but a few small filaments on the sides of the fraenum, they
are divided the same as the filet with scissors, and with the same precautions.
We divide in the same manner those which are not unfrequently established
between the cheeks and the margin of the tongue, in consequence of mercurial
inflammation of those parts ; as also of other phlegmasiae of the mouth,
examples of which have been communicated to the Academy by Messrs.
Duval, CuUerier, and Bernard. If they are of some breadth, they should be
excised instead of being simply divided. After having been detached from
the buccal wall by a stroke of the scissors, they are again taken hold of near
the tongue, and removed by a second stroke of the same instrument. They
may likewise be removed by seizing each in its turn about the middle with
forceps, while the edges are detached with scissors or the bistoury.
2. When these adhesions are intimate, or as they are termed, cellular and
■^ not membranous nor filamentous, the dissection has to be performed with
OPERATIVE SURGERY. 417
great management and precaution. The surgeon, placed behind and at the
right of the patient (whose head is bent against a pillow, the arm of a nurse,
or the breast of an assistant), tries to separate by means of the left index
finger, a spatula, or some appropriate instrument, the free part of the tongue
from the point of the mouth to which it is attached ; he divides gradually
with a straight bistoury, chipping as it were all the lamellae and all the unna-
tural ligaments which it is intended to destroy, recollecting, at the inferior
region especially, to incline the edge of the knife towards the wall of the
mouth, or to separate it as much as the state of the parts will admit from the
body of the tongue itself, in order more certainly to avoid the vessels; to have
the blood sponged as it flows during this dissection ; to stop from time to time
to allow the patient to breathe and gargle, and if there be hemorrliage to
cauterize wdth heated iron ; in other cases he is to prescribe some styptic or
astringent wash ; and concludes by passing his finger over all points of the
wound to satisfy himself that no prejudicial adhesion exists. Mild gargles,
frequent and extensive motions of the tongue, carrying the end of the finger
between the divided surfaces to prevent readhesion, are all that remain to be
advised for completing the cure, which is generally effected from the fifth to
the thirtieth day, but which requires all this attention to be certainly accom-
plished.
^ § 3. Excision.
History, — Gangrene, induration, fungous tumors, schirrus, and cancerous
ulcers, are the principal affections which may require extirpation of the tongue
in whole or in part. This is an operation which has but lately entered into
practice. From the idea that the tongue is the exclusive organ of speech,
although J. Lange is said to have performed it several times on account of
gangrene, such a resource was only thought of with trembling before Louis
showed that many individuals deprived of a great part of this organ have con-
tinued, nevertheless, to speak and appreciate the taste of substances. The la-
borer spoken of by Roland of Saumur, who had lost his tongue as far as its root
in consequence of gangrene, spoke, spit, and swallowed without difficulty,
and had perception of tastes ; the girl, observed at Lisbon by De Jussieu ;
Margaret Cuting, mentioned in the Philosophical Transactions ; Marie Gulard,
quoted by Bonami and Louis ; the girl, A. M. Federlin, whose story was
made known by Auran; the young man w^hose tongue was torn out by the
corsairs because he would not become a mussulman, and whom Tulpius
affirms that he saw; and another, observed by Zacchius, who had had his
tongue cut out by robbers, were in the same case. It is known, besides, that
in Germany, Italy, Spain, &c., malefactors were for a long time punished by
cutting out the tongue, and that for the most part they still preserved the
faculty of speech. Every one, in fine, is acquainted with the two cases
related with so much simplicity by A. Pare ; first, of a mower who had been
dumb for three years from having lost a portion of his tongue, and being
tickled by one of his comrades while holding a vessel between his teeth, made
an effort, and to his great surprise uttered several words ; and beginning from
this adventure learned in the end to speak distinctly with his porringer or a
little cup of wood : second, a youth whose tongue had been cut out, recovered
53
418 NEW ELEMENTS OF
his speech by making use of the instrument invented by the above mentioned
mower. But if it is well proved that the loss of the tongue is not always
followed by complete loss of speech, it is no less proved that its amputation
has more than once been performed without very evident necessity. It is dis-
pensed with at the present day, for example, and Pimpernelle is not imitated,
although the organ be so swelled as to cause it to protrude, unless there is also
a true scirrhous or cancerous degeneration.
Manual. — The operation is conducted in different modes, and must vary
according as the disease occupies one portion more than another. Hooked
forceps and curved scissors are sufficient for the excision of pedunculous
tumors, wiiicli seldom occur except on the dorsal face of the tongue. The
ligature would not have the same advantages; and to prevent any doubt of
having removed the whole, it would be well to sear the bottom, of the wound
with a hot iron. If the alteration is confined to the tegumentary layer,
which, it may be remarked, is much more common than is thought, it will be
requisite, as proposed by Lisfranc, and as Walens, in imitation of Bartholin,
seems to have practised long since, only to remove the degenerated laminae,
and to spare with prudence the fleshy tissue which ordinarily remains sound .
^^'hen the cancerous ulcer is deeper, and situated on the edges, the curved
bistoury is no longer used to destroy it, as by the surgeon mentioned by
Ruysch. The point of the tongue, wrapped with a dry cloth, is drawn out by
the hand of an assistant, who inclines it to the side opposite the disease. The
operator, armed with a straight bistoury, commences by an incision of several
lines on the inferior face and along the whole length of the organ; he then
makes another upon the dorsal surface, and thus includes the cancer and even
a certain portion of the sound parts ; then lifting it with the forceps or hook,
promptly completes its excision. Actual cautery, without being absolutely
required, may become necessary in the end, as in the preceding case. When
the disorganization is of greater depth ; when especially it extends further
backwards, and when besides it appears possible to save one half of the tongue,
we may be allowed to tliink of the ligature which M. Mayor, of Lausanne,
calls the ligature en masse. It will be more secure from hemorrhage than the
bistoury ; and, applied in a certain manner, nothing prevents its being carried
to the neighborhood of the larynx. The process of this surgeon is one of the
most easy. The organ is first transpierced from beneath upwards and from
before backwards, at its most remote part with a good bistoury, which being
drawn forwards divides its whole length into two equal parts without touching
the neighboring arteries. The operator then carries a noose of strong cord
of threads over the affected division, to a point beyond the disease; passes its
two ends separately into a metallic head of a square shape and pierced with
two openings slightly convergent ; then, together, through four, five, six, seven,
eight, or nine balls of the same nature pierced with a single hole, as the beads
of a rosary, and finally tlirough a canula designed to support and push forward
these beads, and which itself is to be supported by a tourniquet or little axle,
on wliich the extremity of the ligature is fastened. Having thus embraced the
base of the flap which is to be destroyed, he turns the little axis, and when the
constriction is carried sufficiently far, fixes the free portion of the apparatus to
the labial commissure either by means of a thread or with a small bandage.
Daily, and even several times during the day, pressure is increased in the same
OPERATIVE SURGERY. 419
manner. The tissues become blackened and soon mortify and fall off, or mar
be excised without danger on the third or fourth day. The serre-noeud of
M. Mayor, a real improvement of the instrument deyised bj Messrs. Bouchet
and Braun, has the advantage in consequence of its flexibility of moulding
itself without difficulty to the inequalities of the tongue, and of occasioning
but little obstruction in the interior of the mouth, and of allowing a constric-
tion at the same time gentle, firm and permanent. When it cannot be had,
the serre-noeud of Desault, or that of Levret, may be here employed as well
as for the ligature of polypi in general. If the whole breadth of the tongue is
to be removed only at its point, or even near its base, the ligature will still be
applicable. The confirmation of this is to be found in the observations of La
Motte and Godard, each in a different case. Sir Ev. Home and Mirault passed
a double ligature through the centre, and brought its two portions to be tied on
the sides of the organ, which was thus divided, and dropped off by suppura-
tion. But whenever the tumor does not extend too far backwards, and a little
sound tissue is found on its edges, excision with a cutting instrument is pre-
ferable. Louis, like the ancients, after having seized it with a hooked forceps,
such as the forceps of Museux, performed the amputation of the tongue by
cutting it fairly and simply across with a bistoury. At present a much more
rational process is followed. Having seized the morbid mass with a strong
hook or hooked forceps, the surgeon with one hand draws it out of the mouth,
and with the other circumscribes it, and removes it with two strokes of the
scissors from the sound parts, in the form of a V, the point of which looks
backward and should fall upon the median line; he immediately approximates
the two sides of the wound and unites it by three stitches, one on its dorsal
surface, the second at its point, and the third on its inferior surface. Its agglu-
tination is often complete by the second day; the threads may be brought
away on the third or fourth day, and the cure is generally complete about the
eighth or tenth: such at least are the observations of M. Boyer, M. Langen-
beck, &.C. By this mode the deformity is as little evident as possible, and the
exact coaptation of the bleeding surfaces soon arrests tiie hemorrhage enough
to render unnecessary the employment of any other haemostatic means. Trans-
verse amputation ought therefore to be reserved for cases which leave no chance
for the formation of lateral flaps. Every tumor, whether scirrhous or car-
cinomatous, which does not penetrate too deeply, and which is prominent at
the periphery of the tongue, may be easily destroyed by the process of Faure
or of Louis ; that is, with curved scissors or the actual cautery. Those which
penetrate to the fleshy tissue and are situated on the surface or one of the
edges without going too far backwards or invading the whole breadth or thick-
ness of the organ, require on the contrary the use of the bistoury by the pro-
cess which I have pointed out, and which approaches a little the method of P.
le Memnonite. If the disease, although very extensive in surface, remain super-
ficial and leave the tissues sound beneath it, we must follow the indication
pointed out by Walee, imitate LislVanc, dissecting and removing what is dis-
eased, and respecting and preservino; what is not. If it be necessary to destroy
an entire half of the tongue including its base, the ligature of M. Mayor is
applicable, and in my opinion to be preferred. While, if it become necessary
to remove the whole, the process of Mr. Home has the advantage ; as well as
420 NEW ELEMENTS OF
in all cases m which excision, after the manner of M. Boyer, is not sufficient
to remove the tumor or centi'al change of structure.
After Treai7iunt. — It is extremely rare that after any of these several ope-
rations there is need of dressing or apparatus. But in the contraiy case the
pocket of Pibrac would be useful. It is a little purse destined to lodge the
free or movable portion of the tongue, and may be lined v.ith lint or any
other piece of dressing. The two branches of silver which sustain its base, and
support each a riband at its free extremity, are bent in such a manner, that by
drawing upon what remains without the other portion is forced to enter the
mouth. Supposing a perplexing hemorrhage to supervene, a hemorrhage which
the resources pointed out above shall not definitively arrest, i ecourse must be
had to the ligature; then the lingual artery is to be sought for at its passage
over the os hyoides, unless it be thought best to tie the carotid itself. It would
even be prudent to begin with this, if the tongue is to be amputated near its
root with a cutting instrument.
Art. 4. — Isthmus of the Fauces,
§ 1. Excision of Part , or the Whole of the Tonsils,
History. — After repeated inflammations, the tonsils often remain so large as
to impede deglutition, hearing, and even respiration. The hardness which they
at the same time acquire, has for centuries given rise to the opinion that they
pass to a schirrous state. But since the time of Claudinus, and more espe-
cially of B. Bell, the falsity of this opinion is generally admitted ; although
to my surprise I find it advanced in the recent work of Messrs. Roche and
Sanson. Every surgeon at the present day, knows that the induration of the
amygdalae with swelling is but an hypertrophy ; and tliat it seldom or never
gives place to scirrhus or cancer. The treatment to which it has been sub-
mitted has been very various. Without counting scarification, which was
recommended by Asclepiades the Bithynian, Heister, Maurain, Celsus, and
some moderns, it has been treated by cauterization, ligature, extirpation, and
excision.
1. Cauterization. — Mesue, who appears to have been the first who dared to
apply caustics to the tonsils, made use of the actual cautery. Brunus
followed the same practice, at least when he intended to destroy the whole of
the disease. Mercatus, who comes later, adopted a golden cautery moderately
heated, which he carried through a canula to the tonsil to be burned. M. A.
Severin, less particular than Mercatus, was content with an iron instrument,
and used it the same as Affisius his friend, only upon tonsils with a broad base.
After saying that Ed. Mol cauterized the tonsils very successfully by
piercing them repeatedly with a hot iron, Wiseman still admits that he
prefers the use of escharotics, which Junker, Heister, and Freind ,advise
under different forms. The lapis infernalis, employed successfully by Mo-
rand, is still sometimes used ; but it is not useful, nor are the sulphates of iron,
of copper, or of alumine, except in cases of recent or inconsiderable indura-
tion. Red hot iron, which Louis appears to have partially adopted, is prefer-
OPERATIVE SURGERY* 421
able when there is need of free and energetic cauterization ; but is evidently
applicable only to fungous and cancerous tonsils, except in cases where it is
feared that some part is left which ought to be removed, that the disease will
be renewed, or the blood escape too plentifully after excision. But as these
different circumstances, pointed out by Percy and Boyer, are rare exceptions,
it follows, even receiving them as facts, that cauterization should scarcely
ever be admitted.
2. Ligature. — Devised to avoid hemorrhage with certainty and excite less
apprehension in the patient, and employed for a long period in France, the
ligature h^d yet been clearly prescribed by no one before Guillemeau, who in
applying it made use of a kind of serre-noeud forceps, very ingeniously
arranged. F. de Hilden is tlie second author who recommends it. The
canula, supplied with a grooved ring which he had invented for this purpose
to carry and fasten the thread, has not been more generally adopted than the
instrument of Guillemeau. Cheselden, who was one of its principal partisans,
applied it by means of a simple probe when the tumor was pedunculous. In
other cases, with a curved needle he passed a double thread through the
gland, in order to strangulate each half separately. Sharp operated exclu-
sively in this manner, which Lecat, after Castellanus, Levret, and Heuermann
modified, particularly in using threads of different color, so that it was impos-
sible to confound them. Bell took a silver wire or a piece of catgut; fixed it
in a canula slightly curved, which he carried to the superior part of the
pharynx through the corresponding nasal fossa; then enlarging the noose
with his finger placed it around the tonsil, and used his canula as a serre-
noeud. A thread of Brittany carried through the mouth on a double hook,
and fixed by means of his ordinary serre-noeud, sufficed with Desault.
Heuermann maintained that the polypus instruments of Levret answer best for
this ligature, which may be equally performed with the chaplet-shaped instru-
ment of M. Moyer, or in imitation of C. Siebold, by means of a silver wire
conveyed with forceps. The disadvantages of the ligature, already remarked
by Van Swieten and Moscati, are obvious to all, and are so inherent in the
operation itself, that no one now employs it, notwitlistanding the success
attributed to it by Dr. Physick; and we can scarcely comprehend the efforts
made recently in England by Messrs. Chevallier and C. Bell to restore
its use.
3. Extirpation, which Celsus seems to mean by these words : oportet digito
circumradere (tonsillas) et evellere, has been positively prescribed by Paulus
Egineta, ipsam totam (tonsillam) ex fundo per scalpellum resecamus), who
performed it with a curved bistoury. Ali Abbas invented for this purpose a
kind of hook which he called senora, and Abul-Kasem a small knife in form
of a sickle. Instead of the ancylotome of Paulus, J. Fabricius advises first
to insulate the gland with an elevator, then to seize it with the forceps and
draw it dexterously forward, so that it shall yield without difliculty, and
as of its own accord. It may be possible, strictly speaking, to extract the
amygdalae by enucleating them with the nail and the finger, as it probably was
done in the time of Celsus ; but this would be to increase unnecessarily the
sufferings of the patient, and it is evident that such an eradication must be
dangerous. For the rest, extirpation of the tonsils is entirely useless ; rescis-
422 NEW ELEMENTS OF
sion has for a long time superseded it. If however it is to be tried, nothing
can be more simple. A hook, or the forceps of Museux, to draw forward and
disengage the gland from between the columns of the velum palati, and a
narrow probe-pointed bistoury to cut its roots, will suffice as in ordinary
excision. Care however must be taken not to go beyond the lateral limits of
the pharynx, else the venus plexus or some still more important vessel, the
carotid for example, which is found on the sides of this muscular funnel, may
be wounded, and thus cause a formidable hemorrhage.
4. Excision. — Although Aetius is the first who formally declared that only
the projecting portion of the tonsils should be removed, and that its extirpa-
tion was never necessary, yet rescission had been recommended before his
time. The operation which Asclepiade designates under the name of
homoirotomie can be nothing else. And has not Celsus also described it in
this phrase ? Si ne sic quidem resolvuntur, hamulo excipere et scalpello excidere.
Those who have admitted it sinco, have nearly all attempted to modify more
or less the method of performing it. Rhazes says that the tumor is to be
seized with a hook, and one-fourth of it to be cut off; but, according to him, it
is so dangerous an operation that it is better to have recourse to bronchotomy.
Instead of the hook and ancylotome of the ancients, of the curved bistoury
and double hook of Mesue, Wiseman begun by tying the tonsil, and then
used the thread as a hook while he excised the gland with scissors. Heister,
as well as Mesue, speaks of a double hook and bistoury. Moscati, who was
at first the partisan of the ligature already proscribed by Cavallini, and who
afterwards practised excision with a curved bistoury fixed on a slip of wood,
adopted a different process : he began by incising the tonsil crucially with a
convex bistoury, after which he cut off its four portions separately, leaving
intervals of three or four days between the operations. Maurain, who justly
criticises the method of Moscati, prescribes, like Levret, that the whole pro-
tuberance be taken off at a single stroke with curved scissors made expressly
for the purpose. Lecat returns to the double hook of Heister, and advises
a small concave knife with a blunt point, or curved and blunt scissors. At
the same epoch Foubert recommends the gland to be embraced with polypus
forceps, and pressed forcibly in order to contuse the vessels, while the exci-
sion is performed by a single stroke of the bistoury. Caque, of Rheims,
boasts very much of a simple hook and a blunt pointed knife, with an edge
nearly straight and bent upon the handle. Louis asserts that the ordinary bis-
toury will serve the purpose, and that if the gland is cut from below upwards, it
will certainly prevent its falling into the opening of the larynx and exposing
the patient to suffocation, as in the cases which excited so much apprehension
in the minds of Wiseman and Moscati. With this view another surgeon o
Rheims, Museux, invented the forceps which bears his name, and maintains
that the tonsil once seized by this instrument cannot possibly escape, and that
nothing is then easier than its excision either with scissors or the bistoury.
Desault preferred tlie ordinary double hook and the kiotome, a kind of flat
canula six inches long by one broad, deeply hollowed out at its extremity, to
receive the tonsil, enclosing a movable blade, cutting at the point which
traverses the hollow of the sheath, and acted upon by the thumb. This instru-
ment of Desault, although ingenious, is no longer used, at least in France.
OPERATIVE SURGERlr. 423
A harrow bistoury, straight and blunt pointed, such as is found in every
surgeon's case, is much more convenient, and, as M. Boyer observes, merits
preference in every respect.
Appreciation.' — Authors have differed so much in the manner of performing
an operation so simple, only because in indocile subjects, children for ex-
ample, and those who have a small deep mouth, or where it is opened with
difficulty, it often presents great difficulties. A glance at the several stages
of the operation will permit us, I trust, to reduce to their true value the
principal assertions of the operators who have just been quoted. The first
thing then to be done is to keep the moutli of the patient open and govern
the motions of the tongue. Hence the various glosso-catoches of the ancients,
and the numerous species of speculum which have succeeded each other from
the time of Ambrose Pare to our own; hence the chevalet, the handle of
which, curved like an S, enabled Caque to draw back the labial commissure
and keep the jaws apart ; the plate of silver, which was applied on the tongue,
while its handle, a little more elevated, rested upon the inferior dental range,
which it depressed ; the other more complicated instrument, proposed by M.
Lemaistre at the Hotel-Dieu, afterwards by M. Gamier to the medical
society of emulation, which, without obstructing the movements of the ope-
rator, was to keep the mouth steadily open and the tongue depressed ; the
blade of box or ebony bent at a right angle, much resembling for the rest a
shoeing horn, and which is regarded by Messrs. Roche and Sanson as very
advantageous ; hence again the instrument, at the same time more complete
and more complicated, of M. Colombat. But a spatula, or the handle of a
silver spoon and a piece of cork, are of equal avail and less embarrassing
than any of these ingenious inventions. The preliminary ligature of Wise-
man is evidently an episode more vexatious than excison itself. As to the
hook, it is to be feared, that if single it will tear through the tissues
and escape ; and if double, it may be too difficult to disengage it, and particu-
larly if quadruple, as in the forceps of Museux. It is objected besides to
these last that they impede by their volume the play of other instruments,
and that they are not easily borne by the patient. In fine, the three-pointed
hook, devised by Marjolin on the occasion of a young subject difficult to
manage, would prove still more embarrassing than the instrument of the
surgeon of Rheims, if it should become necessary to withdraw it before the
end of the operation. These objections, no doubt, have some foundation,
although the greater part of the disadvantages pointed out are very trifling.
After all, the choice of the hook is not an important affair. Provided the single
hook has a certain degree of strength, its curve a certain extent, and that
it seize the gland behind at the union of its external third with its internal
two-thirds, it will allow of traction with as much force as the double hook,
and will not lacerate the tissues more. Neither Louis nor M. Roux has found
in it any thing to complain of, and for my own part I have always found its
use very convenient. For the rest, the double hook employed by Desault, and
which is now daily used by M. Boyer and many others, has in my opinion
only the disadvantage of being somewhat difficult to place. The forceps of
Museux, preferred by M. Dupuytren, although less easy to handle, present an
advantage which is not found in the hook of M. Marjolin — that of not being
liable when withdrawn to wound the parts within the mouth.
424 NEW ELEMENTS OF
As to cutting instruments there is no choice except between the scissors
and the probe-pointed bistoury. With the former there is less danger (espe-
cially by selecting scissors with blunt points, or buttoned and curved in the
fiat) of dividing what it is necessary to preserve. But the division is less
neat, and they occupy a little more space in the pharynx and mouth than the
bistoury. When pressed between their blades the gland sometimes retreats,
and requires to be divided at several strokes. With respect to the bistoury,
the reason for excluding all but the probe-pointed is that the others will almost
infallibly wound the posterior wall of the pharynx, the external side of which
it would also be very easy to penetrate. The knife of Caque is too large;
the narrower and straight bistoury is undoubtedly the best that can be em-
ployed. If the kiotome had not been recommended by a man as celebrated
as Desault, and regarded in so advantageous alight by Mr. S. Cooper, it would
scarcely deserve to be mentioned. The instruments being selected, it remains
to be considered how we shall perform the excision. By cutting from above
downwards, as advised by some, there is reason to apprehend that the bistoury
will wound the base of the tongue, and if only held by a pedicle, the gland
may escape and fall upon the larynx ; but then it would be so easy by carry-
ing the finger into the fauces to bring it through the mouth, that the acci-
dent which was on the point of happening to Wiseman and Moscati, is in
reality scarcely to be feared. Louis, who dreaded it, says that by cutting^
from below upwards nothing of the kind is to be apprehended, and the tongue
will be out of all danger of being touched. Admitting the justness of this
principle, Messrs. Boyer and Marjolin have nevertheless thought proper to
adopt it only in part. According to them, if there is no danger to the tongue
it is otherwise with the velum palati, and to avoid all risk to this part they
follow the advice of Richter, cutting first from above downwards, then from
below upwards, and conclude with the middle portion of the tumor. There
is nothing to censure in this excess of precaution, except its inutility. M.
Roux operates generally like Louis, and finds the method sufficient ; and I
have no reason to regret having done the same. If care is taken to make the
tonsil project sufficiently by drawing it forward, and to rest a little of ihe
flat part of the instrument against the columns of the pharyngeal isthmus, as
if to shave oft' its curvature, a much neater and quicker section is obtained
there without any real cause for apprehension.
Manual. — The patient is seated on a chair fronting a window, so that the
light may fall directly upon the bottom of the fauces, while the head is held
back by an assistant. Placed in front, the surgeon fixes a cork, shaped for the
purpose, as deeply as possible and vertically between the molar teeth of one
side, so as to keep the jaws separated ; he depresses the tongue if it is in the
way, and draws out the commissure of the lips ; catches the tonsil and engages it
firmly from behind with his hook, using the left hand for the left side and the
right hand for the right ; he pulls it forwards and disengages it from between
the columns ; takes in the other hand the bistoury, enveloped with a linen fillet
to within ten to fifteen lines of its point, carries it betv/een the hook and the
tongue beneath the base of the gland, turns its edge upwards, and cuts freely by
a sawing movement, as if to make it describe a segment of a circle which will
terminate at the base of the uvula, and thus detaches all the superfluous por-
tion of the tumor at a single stroke ; he then withdraws at once the bistoury, the
OPERATIVE SURGERY. 425
hook, and the excised mass, relieves the jaws of the cork which fatigues them,
lets the patient spit, and gives him cold water or vinegar and water to wash
and gargle his mouth. If only one tonsil be affected, the operation is over ; if
botli, he lets some minutes elapse, the blood ceases to flow, and he proceeds
to the excision of the other in exactly the same manner. Several days may be
permitted to intervene, if the patient, being fatigued, absolutely requires it ;
but in general they choose to be relieved at one sitting rather than to return to
it at separate periods, and the pain they experience is commonly so trivial that
they submit to it without much apprehension.
£fter Treatment. — If the blood is not soon arrested, a solution of alum,
water of Rabel, or any other styptic liquor, may be immediately given as a
gargle, or applied to the wound alone by means of forceps, if it should be
necessary to use it energetic and very concentrated. In case of imminent
danger actual cautery forms a last resource, which must not be neglected, and
which is much more efficacious than the complicated compression proposed
by Jourdain. In an adult, upon whom I operated in the beginning of 1831,
at the house of Madame Reboul, the loss of blood at the end of two hours was
such that it was necessary to apply powdered alum immediately to the
wound. If a bungler had opened the carotid, as M. Portal, A. Burns, and
Beclard say they have seen, the ligature of the primitive trunk would still
offer some chance of safety. For the rest, the medical treatment consists of
emollient gargles and diluent drinks, and the regimen of soups, broths, and
afterwards a little more substantial aliment. Generally no fever supervenes,
and from the fourth to the fifth day the health is in a great measure re-
established.
§ 2. Abscess ; Incision of the Tonsils.
The surgeon is sometimes obliged to open with an instrument abscesses
which form in the substance of the tonsils, in consequence of phlegmonous
inflammation. The sharpened iron of Hippocrates and Celsus, the long
bistoury and needle used by Leonidas, the razor of Lanfranc, the small piece
of polished wood of Plater, the sagittella of Arculanus, the beaked bistoury
invented by Vigo, the pharyngotome of J. L. Petit, that of Jourdain, and the
lancet of Roger of Parma, are all advantageously superseded by the ordinary
bistoury in this trivial operation. Pressure with the finger or the nail, or an
emetic opportunely administered, very frequently suffices. The mouth and
the patient are disposed as in excision of the tonsils, and the bistoury is to be
wrapped with a bandage until within six lines of its point, before it can be
allowed to be plunged into the abscess. The opening of abscesses which are
sometimes developed in the substance of the velum palati, the uvula, or even
the base of the tongue, is performed with the same precautions and requires
no farther care.
§ S. Excision of the Uvula.
The elongation of the uvula, whether from infiltration, inflammation, or
organic degeneracy, is a condition which received much more attention from
the ancients than from the moderns, and perhaps deserves more consideration
than is generally accorded to it at the present day. From its contact with
54
426 NEW ELEMENTS OF
the base of the tongue, the apex of the uvula produces a very Inconvenient
tickling, and sometimes gives rise to symptoms which seemed to belong to
much more serious causes, gastritis and phthisis for example, and which may
lead to serious errors of diagnosis ; as well as of therapeutics, if the surgeon
is unacquainted with their peculiarities. Consequently, it is important that
there should not be too much delay before applying a remedy to alterations of
the uvula ; and its removal, it is to be remembered, as proved by Physick,
Beckern, and liisfranc, is the only means of removing certain obstinate symp-
toms which are apt to be mistaken for more serious affections.
1. Cauterization. — The inflammation of this part, even when acute, yields
readily to cauterization with nitrate of silver, when not too far advanced. I
have used it, like M. Toirac, in many patients, and found in it nothing but
what should meet with approbation. The mixture of quick lime, tartar, alum,
and vermilion, praised by Demosthenes, and the caustics in general proposed
by Galen, are at most applicable to cases of serous infiltration. The cauteries
of gold or iron, used by Montagnana and Arculanus, the nitric and sulphuric
acids, proposed by Vigier and Nuck, are now justly bandoned. No one at
tile present day would follow the ridiculous advice given by Mesue, after-
wards repeated by Nuck and Bass, which is, to pull the hair to the point of
tearing the skin from the cranium and tie it with a ribbon near the base, after
forming it into a toupet.
2. Astringents. — Sal ammoniac, nut-galls, according to S. Largus ; walnut-
shells, according to Galen ; burnt alum, to Rhazes, and pepper and ginger,
still recommended by Purmann, are scarcely used at present, except by old
women and country people, who, when the palate is down, think also to raise
it by passing beneath it a silver spoon considerably heated.
3. The Ligature, carried round the base of the organ by means of the grooved
ring of Castellanus, as Pare directs, with the porte-ligature of F. de Hilden
and Scultetus, or in any other way, without being as dangerous as Dionis
pretends, is nevertheless unnecessary; and excision with a cutting instrument
is the only means which is now opposed to chronic lesions which have pro-
duced the elongation, or what is termed the fall of the uvula.
4. JSxcision is an operation, moreover, which has been practised in every
age and in various modes. Hippocrates treats of it, and directs it to be per-
formed with dexterity. Celsus and Galen followed the same process. Paulus
had instruments express — a staphylagra to hold the organ, a staphylotome to
cut it, and a staphylocaust to cauterize the wound. He mentions still another
instrument, invented by Serapion. Mesue, who forbids the uvula ever to be
cut away entirely, excised it with a golden bistoury reddened in the fire, after
having engaged it in the ring of a sheath made for the purpose. In place of
this sheath, G. de Salicet directs the employment of a tube of elder, in which
he placed the uvula to divide it either with hot iron or the bistoury. Guy de
Chauliac advises forceps or a hook, a concave bistoury or scissors. The
scissors, without forceps or hook, were sufficient for Fabricius, M'ho then cau-
terized the wound to recal its vitality. A Norwegian peasant, Thorbern,
invented an instrument in part similar to that of Mesue and Arnaud, that is,
a kind of kiotome, which opens to engage the uvula in a circular hole near its
extremity, which has only to be closed to complete the operation. Job a Mek-
ren, who saw the uvula extend to the lips, is of opinion that nothing can be
OPERATIVE SURGERY. 427
employed more convenient than scissors with long blades. The instrument
of Thorbern, improved bj Raw, soon after reproduced by Bass under the
form of a spatula funiished with a cutting tongue, did not prevent Fritze from
making further modifications. Levret, who was also a partisan of the ligature,
has extolled scissors with concave edge (as for the tonsils), and the polypus
forceps. Richter found that scissors with blunt points served his purpose very
well ; and B. Bell adopted a curved bistoury, probe -pointed, and nearly similar
to that of Pott for hernia. But the scissors of Percy are the most ingenious and
the most simple for the excision of the uvula. A prolongation of three or four
lines, bent at a right angle, terminates one of their blades, and prevents the
organ slipping before them when once it is engaged. Their only fault, a&
well as that of most of the instruments mentioned above, is that they are not
indispensable and can answer no other purpose ; whence it follows, that the
new staphylotomes recently invented by Messrs. Rousseau and Bennatti are
also superfluous instruments.
Manual. — The patient is seated as for excision of the tonsils. With the
left hand armed with a fine hook, dressing forceps, or, still better, polypus
forceps, which from the notch or opening at their extremity w ill retain it
still more securely, the surgeon hooks the uvula ; inclines it forward and a
little to the right ; then with straight blunt scissors cuts it by a single stroke
at some distance from its base. It is not with the vain purpose of preventing
its falling into the larynx that we first endeavor to fix it, but, being very pliant
and movable, it would otherwise escape from the blades of the instrument.
Oribasius, Rhazes, Avenzoar, &c., are mistaken in saying that its entire
removal is dangerous, and that it ahvays aftects respiration and the voice.
S. Braun is still further from the truth when he asserts that it constantly pro-
duces dumbness. The case quoted by Wedel, and which tends to prove that
food and drinks return by the nose, is evidently only an exception. The
observations of SchefFer, Becken, Myrrhen, and Physick, fully demonstrate
that the loss of this organ rarely produces any disturbance in the system. It
is better to remove too much than too little, so as not to be obliged to repeat
the operation. Besides, the resolution of the inflammatory engorgement
which soon commences causes the uvula, whose base had been more or less
concealed in the velum palati, to be found much longer than at first there was
reason to expect.
§ 4. Staphyloraphy.
The abnormal divisions of the velum palati are, as in the lips, sometimes
congenital and sometimes acquired. That the first occupy nearly always the
median line is owing to the palatine vault not being completed posteriorly, and
its two portions not united at the usual period. Yet they are found sometimes
a little on one side, but have never yet been seen double. The second, an
ordinary result of traumatic lesions, and more particularly of syphilitic ulcer-
ations, are met with on the right and left as well as in the middle, and in the
form of hollows whose depth is usually limited by the edge of the vault, while
the other kind often extend to the dental range, so as to be continuous with a
hare-lip, simple or double, if the patient is simultaneously affected with that
disease.
428 NEW ELEMENTS OF
A. History. — Nothing from the ancients indicates that they had thought of
overcoming this defect of conformation. More enterprising or more skillful,
the moderns have attempted to fill up this chasm, and their efforts have been
crowned with the greatest success. Casting the eye upon a fissure of the
palate, the idea of staphyloraphy must have presented itself a thousand times
to the mind ; but to think of it was not all-— -the application of the idea was t6
be prosecuted, and no one had ventured. The attempts which M. Colombe
says he had made since 1813, on the dead body, and wished to repeat in
1815 on a patient who refused, have not been known to the public ; that of
which M. Graefe has published the details in Hufeland's Journal for 1817,
and which he dates back to the end of 1816, passed equally unnoticed. It
was then reserved for M. Roux to fix attention on this subject; In 1819, a
young American physician. Dr. Stephenson, gave him the first opportunity.
The operation succeeded to his wish, and formed a kind of epoch. All the
public journals lavished on this chirugical victory the eulogies it deserved.
Dr. Stephenson himself made known his cure in a thesis, defended at London
in 1821. The year following, 1822, Mr. Alcock was not less successful than
the Parisian surgeon. It was then that the rights of M. Graefe to its priority
were brought to mind by his countrymen, at the same time that persons from
all parts came to Paris to witness the performance of staphyloraphy, which
soon took rank among the delicate but regular operations of surgery. There
is every reason to believe, however, that it had been practised before. In his
memoirs on different medical subjects, published in 1764, Robert says in effect :
"a child had the palate deft from the veil to the incisors. M. Le Monnier, a
very skillful dentist, attempted with success to unite the two edges of the fissure ,
firstm?Lkin^ several points of suture to hold them together, and then wade them
raw with a cutting instrument. Inflammation supervened, which terminated
in suppuration, and was followed by union of the two lips of the artificial
wound ; the child was perfectly cured." A child, a fissure, the suture, the
making raw, the approximation, the cure, all, notwithstanding the rather vague
expressions of Robert, scarcely permit us to doubt that his dentist had really
recourse to staphyloraphy, and not to the suture of a simple perforation of
the palatine vault. This operation is then in every respect a discovery
entirely French. It is, to proceed, so frequently indicated, that at the end of
1829, M. Rosa had himself performed it forty -five times. M. Jousselin of
Liege, had two successful cases, and M.Beaubien a third. M. Caillot, of Stras-
burg, has published a fourth, and more recently, in 1823, M.J. Cloquet a fifth.
M. Morisseau has just published a sixth instance of success, obtained by him
at Sable, in the case of a female twenty years old ; and M. Bonfils has com-
municated another of about the same time, to the society of practical medicine
of Paris. It appears, moreover, that in France it has been carried from its
first step to the highest degree of perfection possible. It is otherwise in Ger-
many, where they are constantly attempting to improve it. Instead of the
term uranoraphy, proposed by M. Grsefe, others have wished to substitute the
terms velosynthesis, kyonoraphy, uraniskoraphy , &c. MM. Doniges, Ebel,
Hruby, Dieffenbach, Wernecke, Lesenberg, Schwerdt, and Krimer, have all
endeavored to simplify the instrumental apparatus; and in England, Mr.
Alcock has not adopted in every particular the method of M. Roux ; its every
stage has been discussed, and deserves to be so.
OPERATIVE SURGERY. 429
First Stage. — Cauterization with muriatic and sulphuric acids, caustic,
potash, tried by M. Graefe, or even with the tinct. cantharides, lapis infernalis,
and hot iron itself, proposed by MM. Ebel, Wernecke, and Doniges, is not
more efficient in making raw the fissure of the velum palati than that of the
lips. Excision in both cases is indispensable. With dressing forceps, a little
concave and thin, M. Roux seizes successively the two portions of the palate
or division near their free extremity, taking care to include but a very small
portion of their edge ; he then detaches, proceeding from below upwards and
from behind forwards, a strip a line in thickness, which he prolongs as far as
their angle of union, and even beyond it if the osseous vault is complete.
For this purpose a straight bistoury.^ probe-pointed and very narrow, con-
ducted in the manner of a little saw, appeared to him preferable to the
scissors bent upon their handle near their heel, which he at first devised, and
which he sometimes uses even now to commence this excision. In the
beginning M. Graefe, to fulfill this indication, used in the first place a long
forceps resembling in other respects dissecting forceps, bent laterally near the
point and terminating in a double hook or two small bifurcations ; secondly,
an uranotome, too complicated for me to describe here, which is in its body some-
thing analogous to the syringe of Anel, and in its cutting part to the staphy-
lotome of Raw. At present M. Graefe acknowledges the inutility of this
instrument, and substitutes scissors in its stead. Doctor Hruby has found
that forceps curved like those of Museux, terminating in the form of a crutch,
bent at an elbow near their crossing point, one of the bits of which being
wider than the other makes it resemble in this respect the pincers described
by Dionis, fix very firmly the velum palati during the excision. The forceps
of M. Grsefe, with or without hooks, seemed sufficient to M. Dieftenbach,
who for making the edges raw had a small knife constructed, of which a
lancet narrowed near the heel and mounted on a very long handle will give a
very good idea. In fine, Mr. Schwerdt does not differ from the preceding
authors, except in having his forceps not bifurcated at the extremity.
Second Stage. — The interrupted suture, the only one which can here afford
the means of keeping in contact the two cut edges, is nevertheless applied in
different ways. The needles of M. Roux, short, flat, and of deep curvature,
are not narrower than elsewhere at the heel, which has a large square opening.
The ligature with which he supplies them is a ribband composed of from four
to six threads, well waxed and about two feet long. His porte-aiguille, already
known in the arts, is a kind of forceps with a groove on the internal face of
its branches, which a ring tightens or loosens at will as it is pushed forward
or drawn back by a stylet, which holds it and which slides along tlie whole
length of the handle of the instrument, of which it forms in some sense
an axis. The needles tried by M. Grasfe, in 1816, represent pretty much the
half of an elliptic curve, cut at the ends of the transverse diameter. They
are narrower and longer than those of M. Roux, but their eye is much longer,
and perforates them laterally as in the old suture needles. The forceps
intended to carry them is not pierced by any wire. Two rings two inches
apart, supporting two lateral rods, open or close it by sliding towards the
extremity or on the side of its handle. Now the needles of M. Graefe are
nearly straight and lance-pointed. He has moreover bent near the beak his
former porte -aiguille, so that being fixed by their edge in the hollow presented
430 NEW ELEMENTS OF
by the branches of this instrument, they transform it into a real hook. In
fine, still more recently M. Grgefe has removed the rings from this porte-
aiguille, which at present is nothing more than a jointed forceps, the movable
branch of which works on a centre pivot as in the lithotome cache. The
needles of M. Ebel, perfectly straight, very sharp, and broader in the middle
tJian near the eye, like those of M. Roux, have a square perforation to receive
the thread. Those of Mr. Alcock are curved into an oblong arch, and are
nearly round; M. Dieifenbach constructed them resembling little larding
pins; they have no eye, are straight or very slightly concave, hollowed
in their posterior half, and can receive a leaden wire, which their inventor
prefers to every other material, and which he easily draws through after them
when they are made to pass from the fauces into the mouth and through the
velum palati. His porte-aiguille, still more simple than that of M. Graefe, is
in reality but a forceps with rings, the branches of which are one -fourth
the length of the handles and are bent near their beak almost to a right angle.
The needle and porte-aiguille of M. Doniges compose but one instrument ; it
is a long wire in an ebony handle, bent a little behind, and terminating
in front by a hooked needle, pierced near its point and hollowed on its
convexity to receive the thread. That of M. Lesenberg differs from it by
being formed of two parallel branches, which open and close by the same
mechanism as tlie first porte-aiguille of M. Graefe, so that it is necessary to
open it after perforating the parts, in order that the thread it carries may be
left free, and itself removed without acting on the ligature. In adopting this
needle M. Schwerdt proposed to apply to it the pivot mechanism of the last
porte-aiguille of M. Grsefe, in order to dispense with the sliding rings of
M. Doniges.
Tliird Stage. — Placing the ligatures does not finish the operation. They
3nust also be tied and fastened. In France it can scarcely be comprehended
how for this part of the operation it is necessary, according to M. Graefe,
to add to the instruments already mentioned, first, a little hollow cylinder
pierced on its sides ; secondly, a pair of forceps bent at an angle on the
back near the handle, similar in other respects to the second porte-aiguille of
this author, and grooved with two hollows on the external face and on each
side of its beak; thirdly, a screw, a kind of stopper fitted to the preceding
cylinder; fourthly, a second forceps straight and mounted like the common
porte-crayon of the lapis infernalis ; or, fifthly, along steel wire mounted upon
a handle, swelling and cut square at its free extremity, where are two openings
to receive the two halves of the ligature, and form of itself an actual serre-
noeud, which however can scarcely act except on metallic wires. Sliding it
with one hand towards the palate over the two halves of the thread engaged
in its openings, it soon arrives at the suture, which it tightens as much as is
.desired, and to fix which firmly it is only necessary to twist it by turning it
three or four times on its axis. With the other apparatus the ends of the
ligature are first passed from within outwards through the lateral holes of the
cylinder, which is then seized with bent forceps. It is then puslied on the
threads, which the surgeon draws towards him, taking care on the other part
to keep them engaged in the external grooves of the beak of the forceps until
it touch the palatine vault and the ligature becomes sufficiently tight. Nothing
now remains but to close it by carrying there ^vith the other forceps the screw
OPERATIVE SURGERY. 431
designed to fill it and arrest the threads, and then leave it in place. This array
of unnecessary objects exhibits its own inconveniences without my pointing
them out. In proposing the surgeon's knot, and instead of the instruments of
M. Graefe, a kind of crutch notched at the ends of its cross-piece to receive the
two sides of the thread, which are drawn with one hand while with the other
the crutch is made to slide to the suture, M. Doniges does not reflect that the
fingers will answer the same purpose infinitely better. I do not perceive,
moreover, what real advantage M. Krimer could find in the use of a gold
screw over one of iron, like those of M. Graefe, and of black thread over
white, and oiled over waxed. The method of M. Roux is incomparably more
simple and more natural. After passing one of the two ends of each ligature
within the other, he makes a simple knot, which the index fingers, carried to-
gether to the bottom of the mouth, permit him to tie as tightly as it is necessary.
An assistant immediately takes hold of this knot with the ringed forceps, and
holds it firmly that it may not be relaxed, while the operator fixes it by a
second knot formed in the same manner, beyond which he then cuts with
scissors each of the superfluous parts of the ligature.
B. Manual. — Staphyloraphy is not, properly speaking, a difficult or painful
operation, but it is long, delicate, and fatiguing, and requires great patience on
the part of both patient and operator ; so that it cannot be performed but
on those who desire it, who feel its importance, and who have firmly resolved
to submit to it. It is rare, therefore, that we have to treat children under
twelve to fifteen years of age. It requires no precaution in regimen, but the indi-
vidual should be otherwise in good health. Diseases of the gastro -pulmonary
passages particularly endanger its success in consequence of cough, sneezing,
and the desire of spitting, which commonly accompany them.
The Apparatus, prepared beforehand, consists of, first, three flat ligatures
very regular and flexible ; second, of six needles, one at each end of the liga-
tures ; third, an ordinary porte -aiguille, or that of M. Dieftenbach, if the nearly
straight needles of M. Ebel are preferred ; fourth, a good dressing forceps,
the breaks of which, a little concave, should not exactly touch each other
when closed, except at their point; fifth, a straight bistoury, probe-pointed
and narrower than the one in the common surgical case ; sixth, scissors for
excision and straight scissors to cut the threads ; seventh, corks hollowed into
a gutter at each extremity, to accommodate itself to the form of the dental
ranges ; eighth, a spoon to depress the tongue in case of need ; ninth, several
napkins, a large cloth, cold water and a glass, a basin, and also a little
vinegar.
Position. — Covered with the cloth, with a napkin wrapped round him, his
head supported by an assistant, the patient is to be placed in a good light, as
for excision of the tonsils. A second assistant stands ready to hand the bason
and water as well as the instruments, when wanted. Seated in front, on a
chair of proper height, the operator first introduces the corks between the
molar teeth of each side ; then with the forceps in his left hand, he seizes the
right border of the division, conducts with his right hand the armed porte-
aiguille into the pharynx, brings it forwards, and endeavors to make the point
of the needle strike from three to four lines without the fissure and near its
inferior part to pass through the velum ; he then seizes it with the forceps
transversely when it has penetrated as far as possible into the mouth ; frees its
452 NEW ELEMENTS OF
heel at the moment the assistant opens the porte -aiguille ; without the slightest
jerk removes this last instrument; takes the forceps in his right hand, and
draws the needle completely forward out of the mouth, the ligature following
it. The patient being fatigued, requires to spit and rest a moment. His jaws
are therefore freed from what keeps tliem separate before performing on the
left, with the second needle and the second end of thread, changing hands,
what has just been done on the right. In order not to confound it witli those
which are to follow, it is well to tie the free extremities of this first ligature,
and depress its noose a little into the tliroat to prevent its obstructing the
application of the others. The two ends are then drawn to the commissures,
and held bj an assistant on the sides of the head. The surgeon then places
the second and the third, if it is thought necessary, with the same precautions
and in the same manner, leaving between each two about an equal space.
After depressing the noose an inch or so, and pushing it back in order not
to expose it to be cut by the bistoury, or bent scissors, he takes hold of the
left lip of the fissure by the end of the uvula ; commences with the scissors the
excision of the small lip which he is to take away, and which the forceps is
not to quit, while he continues its separation with the bistoury as far as the
palatine bone; he executes the same manoeuvre on the left lip with the right
hand, and returns to the use of the scissors to smooth the edge, if the action
of the bistoury has not been equal in every point of the abnormal division.
The blood flows, obstructs the pharynx, and often collects in clots about the
threads. The patient is to be rid of it, to gargle, and remain quiet for several
moments. The most difficult part of the operation is now over. The liga-
tures are distinguished, and put in order so as easily to be found again, and
tied one after the other beginning with the lowest. When the gape is
considerable and coaptation seems to be difficult, M. Roux separates each of
its lips from the posterior edge of the palate bone by a transverse incision
from four to six lines deep. The two halves of the velum, being no longer
retained by the hard parts, yield and approximate with surprising facility.
This mode prevents all dangerous pulling on the part of the threads, and the
new wound which is made soon closes spontaneously without giving any
ground for apprehension. To obviate the same difficulty M. DiefFenbach
follows another method. He finds that a longitudinal incision on each side
about four lines from the abnormal fissure is infinitely better than that of.
M. Roux, all the advantages of which it possesses without any of its disadvan-
tages ; that it, too, closes of itself and without injury to relations of the paUtine
vault, and that it allows a very marked elongation along the whole extent of
the flaps which are to be brought together. These two modifications are not
unimportant, and should be admitted ; the first, when the fissure in the soft
parts is complicated with a separation of the bones ; the second, which is more
natural, when it is intended to overcome resistances solely of these latter,
and oppose the retraction of the muscles of the palate. Both prove besides,
that in proposing incision of the posterior face of the lips in hare-lip, the
ancients were not so wrong as moderns have imagined.
Treatment. — The ligatures once tied the operation is finished, and in no
case is any further dressing necessary. It is sufficient that the patient remain
without speaking, and take particular care to do nothing which might cause
him to cough, vomit, spit, or sneeze ; that he take notliing but broth or very
OPERATIVE SURGERY. 433
liquid soups until the suture has acquired some degree of firmness. On the
fourth day tiie middle thread may be brought away ; the next day the highest
may be removed ; the third is to be left until the sixth day — understanding
that they are to be left one or two days longer if agglutination seems still incom-
plete at the ordinary period. It is hardly necessary to mention, that to dis-
engage them from the tissues they are to be cut on the side of the knot, wliich
is held and withdrawn with the forceps. If union has taken place only on the
side of tlie uvula, which frequently occurs when the fissure is prolonged on
the median line of the jaw, there is no reason to be alarmed. Frequently the
opening which results disappears without any extraneous aid in the course of
time ; but the union may be promoted by making the edges raw ; by producing
inflammation with lapis infernalis, as I have seen done by M. Roux ; with the
nitrate of mercury, as M. J. Cloquet tried with success ; or indeed with any
otiier caustic. After all, the patient would be freed from it by submitting to
wear an obturator or artificial palate, if there were not other resources against
the evil.
C. Modifications. — Fortunately it is possible, I think, to remedy it in
another manner. To close an opening of this kind, M. Krimer made an
incision several lines from its edges on each side from behind forwards,
comprising the whole thickness of the palatine membrane. Having thus
marked out two flaps of soft parts, he dissected them up, inverted them upon
themselves, brought them towards the median line, and united them by a suf-
ficient number of stitches, which he was able to remove on the fourtli day ;
agglutination took place perfectly, and the palatine vault was wholly restored.
This is a practice assuredly to be imitated ; and as the occasion will often
present, I am convinced that this idea is a real improvement of staphyloraphy.
Among other proposed modifications, I scarcely find any that may be adopted
with advantage. If the forceps of M. Graefe, improved by M. Schwerdt,
were not in other respects a superfluous instrument, perhaps they miglit take
hold better and more solidly of the parts to be excised than the forceps witli
rings. As the little knife of M. Dieffcnbach might in reality be replaced by
a ceratotome, a lancet a little longer than usual, fixed by a band of linen, or
even by the common straight bistoury, and which has no other disadvantage
than of exposing the posterior wall of the pharynx to be wounded, I see no
great objection to using it instead of the probe-pointed bistoury. Plunged
from the mouth towards tlie pharynx through the velum palati very near the
fissure ; then carried parallel with this fissure, at first forwards or towards the
bones ; then in the direction of the uvula, it would easily separate a slip, the
extremities of wkich, detached only at the conclusion of the stroke, would
evidently render the excision more certain and easy, by furnishing, what is
not found by the bistoury, a double support to the instrument to the last. The
nearly straight needles of M. Graefe or of M. Ebel, introduced by means of
the porte-aiguille of M. Dieffenbach, seem also to present some advantages:
first, that of being more easily loosened than with the ordinary porte-aiguille
when they have passed through the soft parts; then, of presenting less resist-
ance than curved needles to the forceps which is to draw them tln-ough and
bring them out of the mouth. As to the wires conveyed by the lardoires of
M.Dieftenbach — for as far as experience has jet proved that their round form
and smallness of size are not too favorable to cutting the tissues — I will not
55
434 NEW ELEMENTS OF
venture to recommend them. The hook-needles with single or double shafts,
of Messrs. Schwerdt, Donigcs, and Lesenberg, so ingeniously contrived, at the
first glance seem to me, however, worthy of rejection, because it will always
be difficult to disengage tlie thread from them, and withdraw them without
deranging any thing after passing them from the pharynx into the mouth
through the velum palati. Staphyloraphy, which has been practised in Boston
by Dr. Warren, and in New York by Dr. H. H. Stevens, is an operation which
every operator should be allowed to modify according to his particular ideas
and the parts to be approximated. Staphyloplasm, for instance, might ,be
substituteu for it, as was done by M. Bonfils, when instead of a fissure there
is a real loss of substance. A flap sufficiently large cut on the palatine vault,
dissected and inverted from before backward, could be easily adapted to the
form of the opening, and kept in place by the suture. Although incomplete,
the success of the surgeon of Nancy gives us a glimpse of what may be
expected from this resource. The attempt of M. Krimer besides, is altogether
in its favor. If there is an opening in the velum palati instead of a fissure,
hot iron, with which M. Delpech obtained a perfect cure on a child ; the
nitrate of silver, which succeeded with me eventually in a case of perforation
in consequence of syphilitic ulcers ; or any other caustic, should first be tried.
SECTION IV.
Olfactory Apparatus.
Art. 1. — Nasal Fossae.
§ 1. Hemorrhage — Plugging.
Whether the flow of blood from the nose be the result of traumatic lesion
or of a vital congestion; when it resists revulsives, cold local applications,
styptics, and astringents ; or when its duration and its abundance render it
alarming, the surgeon ought to have recourse to plugging of the nasal fossae.
This operation, which is both simple and easy, is performed as follows : a roll
of lint large enough to fill the posterior opening of the nostril, tied round its
middle with a waxed thread, to the circle of which is attached a long single
thread, is first prepared ; other rolls of less volume, or simply raw charpie,
are also prepared beforehand. The operator carries into the pharynx through
the bleeding nostril a gum-elastic sound, a piece of catgut, a lead or silver
wire, a piece of whalebone, or, if at hand, the sound called Bellocq's; brings
through the mouth the extremity of one of these instruments, either by seek-
ing for it with one or two fingers in the back part of the throat or by pushing
the spring of the sound if this be used ; he attaches the double thread to this
extremity, and then withdraws it to place the roll of Lint in the posterior part
of the mouth, carrying with it the single thread ; he detaches the conducting
instrument, now no longer necessary ; draws again on the lint ; engages it firmly
in the affected nostril, wliich is thus closed from behind ; he then separates
the two ends of the ligature which come through the nose ; passes between them
from below upwards and from before backwards the free dossils or the raw
charpie until the front of the cavity is exactly filled ; then crosses them as if
OPERATIVE SURGERY. 435
for tying, and tightens them with all the force he thinks necessary upon this
last tampon so as to push it backwards, at the same time that it acts upon the
other with equal energy to bring it forwards. By this means it is easy to fill
the nostril completely with charpie, or, at least, to seal hermetically the two
openings, and oppose to the hemorrhage an insurmountable barrier. The ends
of thread which come out of the mouth and nose, are to be kept fastened
against the cheek or the cap of tlie patient, until the time of removing the appa-
ratus. This is the only time that the single thread proves to be of use, unless
the surgeon has been obliged to remove and replace several times the tampon
in the posterior nares before finally removing the whole, which should never
take place before the complete cessation of the molimen hemorrhagicum ;
rarely, at the least, before the second or third day. He then cuts or unties
the anterior knot, removes the charpie with a forceps, and leaves in the nose
but the first dossil, which tractions, exerted on the buccal thread, are to draw
down into the pharynx and extract by the mouth.
§ 2. Polypi,
Desiccation, cauterization, the seton, excision, extraction, and the ligature,
may all cure polypus of the nose ; but these several therapeutic methods are
far from being equally efficacious, and deserving equal confidence.
1. Desiccation, for example, is evidently only applicable to mucous polypi in
their early stage ; and it is even doubtful if its result be then very satisfactory.
Thus it is not used at the present day but as subsequent or auxiliary to ex-
cision or extraction. Notwithstanding Aetius, Alexander of Tralles, Ac-
tuarius, and a host of ancient authors, the appearance of success obtained by
M. Mayer with the powder of Teucrium marum does not seem to me calcu-
lated to reverse that sentence.
2. Cauterization is somewhat more worthy of attention ; and I should not be
surprised if the future appealed from the unfavorable judgment pronounced
against it by the moderns. Hippocrates, who advocated it, performed it
sometimes with the heated iron, at others with caustics. Arsenic, the acetate
and sulphate of copper, according to Galen, were preferred by Philoxenes ;
while Antipater and Masa employed vermilion of Sinape. Sandarac, pimento,
pomegranates, oxyd of lead, the root of the ranunculus, quick lime, and pot-
ash, lauded by Archigenes, S. Largus, and P. de Bairo, have since been suc-
ceeded by the butter of antimony, which Garengeot used, after protecting the
sound parts, by placing a plaster between the polypus and the corresponding
wall of the nose, also by the nitrate of mercury, the nitric or sulphuric acids,
or the nitrate of silver. These various catheterics were applied to the disease
by means of setons, tents, dossils of lint, lead wires, metallic tubes, &c., so as
to touch the projecting portion and destroy it by deorees. They were after-
wards superseded by injections of lime-water, solutions of alum, of vitriol,
astringent or styptic decoctions, in a word, by the whole catalogue of desic-
cative substances ; and the annals of medicine prove, that radical cures of
polypus have been effected in this manner. Quite recently, too, in 1827,
M. Wagmer has acquainted the academy with remarkable observations, very-
worthy of exciting attention on this subject if correct. He succeeded in
discovering the secret of a German quack, named Jensch, who had acquired
436 NEW ELEMENTS OF
in his province the reputation of overcoming the most obstinate polypi.
Being master of this secret, which is nothing more than a mixture of sulphuric
acid, butter of antimony, and nitrate of silver, M. Wagmer was desirous of
testing its efficacy, following exactly the rules laid down by the empyric.
According to him, its eftects have been almost miraculous. The fol-
lowing is the process indicated : a piece of metal in the form of a long pin,
with a head of the size of a large pea, is the only instrument necessary.
Having covered the head with a coat of the caustic, it is applied to tlie pro-
jecting portion of the polypus, and the application repeated from two to five
times. Every day the operation is renewed, until the iunwv drops off or is
destroyed. An injection with a solution of alum is made an hour before, and
an hour after each cauterization. After the principal mass has been detached,
it is only touched with the lapis infernalis. The injections are to be con-
tinued for two months; and to restore the sense of smelling, the powder of
napeta (Teucrium verum) is prescribed in the form of snuff. I see no reason
why this treatment should not be tried, at least on timid subjects, or when
the polypus is broader than it is long, and equally difficult to extract or to
tie. It would not be the first time, moreover, that ignorance and gross char-
latantism has given the idea of a prescription of service in the methodical
treatment of diseases.
Jldiial Cautery, which naturally inspires more confidence than the poten-
tial, and which, according to the Arabian physicians, it is sufficient to apply
to the forehead to prevent the reproduction of polypi ; so highly extolled by
Roger of Parma, who applied it to the disease through a canula; by D.
Scacchi and P. de Marchetti, who had the courage to repeat its application
twenty days in succession ; by Purmann, who succeeded three times with
an iron wire heated to redness; by Richter and Acrel, who wrapped the
conducting tube with a moist linen the better to protect the surrounding
tissues, is nevertheless almost wholly abandoned at the present day. It is
sometimes recurred to to destroy the remains of polypi left behind, after other
methods to arrest hemorrhage which sometimes follows extraction, or for
destroying sensible or malignant polypi; but neither even of these cases abso-
lutely require it. In the first, escharotics, which are less alarming to
patients, are justly preferred to it. Plugging may easily supply its place in
the second. In the third, fire, iron, and medicaments are equally dangerous.
This species of polypus which bleeds at the least touch, and often even
without being touched, which alter considerably the physiognomy of patients
and are accompanied with sudden shootings of pain, yield in fact to no remedy,
and constitute the real noli me iangere.
For the rest, the operation is easy when the polypus is not too deeply seated.
The anterior (jrifice of the nose is to be dilated for some days, if the cautery
is to be carried through that passage. A speculum nasi permits us to see the
exact situation of the tumor. After these preliminaries, the surgeon takes a
canula, soldered at right angles at its base upon a handle, or the ends of a
forceps, unless he prefer a simple tube held by dressing forceps, wraps it with
moist cloth, and carries it to the polypus, which may be burnt with a rose or
olivary cautery heated to whiteness. It would be most frequently impossible
to employ this means through the mouth, that is, for polipi of the posterior
buces ; and even in the other case, it is frequently followed with intense
OPERATIVE SURGERY. 437
cephalalgia, and very serious cerebral affections, as Sabatier has several times
observed.
Sd. The Seton is a resource of another description. Three distinct indica-
tions, strictly speaking, may be fulfilled by it. The knotted string, proposed
at first by Paul, or rather by Rhazes, then by Avicenna, and most particularly
by Brunus, to saw the polypi, is a kind of seton quite ingeniously devised,
but which, to say the least, will act as much on the Schneiderian membrane as
on the morbid tumor. The silver wire wound spirally with one of brass, and sup-
ported by two handles, one fixed and the other n^ovable, recommended by
Levret instead of the seton of the ancients, is no longer used in practice. Le
Dran's idea was more natural : passing a hook through the nostrils to take
hold of a cotton string carried into the pharynx by the index finger, or, which
is as well, passing a piece of catgut which was brought out through the mouth
and drawn back through the nasal fossa after a seton had been attached to it.
This surgeon succeeded in destroying a polypus of which several roots had
escaped him. It was then very easy to pass into the nose every day, first a
dossil of dry lint to remove heterogeneous matters, and afterwards dossils
spread with digestive or catheteric ointment, designed to favor the removal of
the particle of the polypus, and cleanse the sore. With this view^ and to attain
this end, Hippocrates and some of the ancients, have extolled the seton ;
while intending to simplify Le Dran's process, Goulard has really made it
more complicated. The hook, shaped to the turnings of the nasal fossas, which
he prescribes in place of the catgut, the fork which he used instead of the finger
for the purpose of carrying the seton behind the velum palati, are evidently
less convenient. After all, the process for passing a seton through i^w^i nostrils
should be in this case the same as plugging those cavities. It is a method, the
advantagies of which are confined to conducting; medicinal substances to some
point within the nasal fossae.
4th. Excision may be referred as far back as Celsus, who names a kind of
cutting blade (spatha) to be used in performing it. Paul cut the polypus with
his spatha polypica, one extremity of w^hich was furnished with scissors, and
tore out the rest with a polypoxiste. Abul-Kasem began by drawing down
the tumor with a hook, and then cut it with a sharp instrument. Others, Scacchi
for example, operated with a simple bistoury, or, like Hutten, with a species of
syringotome, or again, like Nessi, with a curved probe-pointed bistoury. J.
Fabricius condemns these instruments, and emphatically recommends a kind
of forceps in the shape of a double cutting spoon, which M. A. Severin charges
him with havino^ borrowed from Nicollini, without acknowledgment, which
Glandorp, V. Home, and Solingen, have successfully modified, and which
Dionis, Percy, and B. Bell, have thought not worthy of entire rejection. Le
Dran, Manne, and Levret, who under some circumstances also excised polypi,
used no other instrument than the ordinary bistoury or curved scissors. But
of late M. Wathely has returned to the use of the syringotome; that is, a bis-
toury lengthened in the shape of the point of a probe, concave on its edge,
enclosed in a sheath in which it easily glides towards either the point or the
handle.
When the polypus has solidity and is very near the exterior of the pharynx,
it cannot be doubted that the process of Abul-Kasem with a bistoury, or, still
better, with ordinary scissors or those curved on the side, will often succeed
4S8
NEW ELEMENTS OF
ill removing it. The cutting forceps of J. Fabricius may also perform it under
certain circumstances, when in the middle of the nasal fossae. Nevertheless,
excision is an uncertain method, and almost always requires to be assisted by
one of the preceding methods, if we would not wish to see the disease sprout
up again, and consequently it ought not to be preferred except in some special
cases.
5. Extraction, which has for a long time been generally substituted for
excision, is a method not less ancient and on other accounts very important.
From having confounded the cutting forceps with the ordinary forceps, the
moderns have incorrectly attributed the first idea of this method to A. Pare,
or rather to Fabricius ab Aquapendente. It is found clearly expressed in the
books attributed by Sprengel to Thessalus, and to Draco, the son of Hippo-
crates. Even at that epoch there were two modes of executing it. In one, a
piece of sponge firmly tied and fixed by four threads was forced into the
nose, then by means of a long needle it was attempted to carry these threads
into the posterior fauces, to draw down the polypus by means of a forked instru-
ment, and extract it. The other consisted in first tying the tumor with
catgut wrapped with thread, and then extracting it through the pharynx.
Paul and Rhazes speak of this last as a common method. Brunus was for
removing the fleshy excrescence with a crotchet, and G. de Salicet already
recommended the forceps. Aranzi, who devised very long pincers, found a
great advantage in causing the light which was to fall into the nose to pass
through a hole in a window, or a glass globe filled with water. Although this
instrument was lauded by Job a Meckren, yet to Dionis are owing the first
circumstantial details of its rational employment. Adopted since by almost
every practitioner, it has been modified by Sharp, who sometimes used curved
forceps ; by B. Bell, who had the blades pierced with an opening, and by
Richter, who for voluminous polypi invented an instrument with branches to
be separately applied, like those of midwifery forceps. Straight pincers are the
best when the situation of the disease allows their application. By turning
them on their axis, they act on the polypus with a force not to be attained
with the curved ones. These are reserved for tumors which may be reached
and brought through the mouth. As to those which resemble the obstetrical
forceps, they are of real advantage when the mass to be extracted is t6o
voluminous for the ordinary forceps to grasp easily midway in the nasal
fossa. Whatever in other respects may be the dimensions or general form of
the forceps, it is best that their blades be pierced through, or concave within
like a spoon, and furnished with little points or notches called deyits de loup, to
render the hold more secure. They should also be as stout as possible,
otherwise they are liable to be bent. Extraction after the manner of the
ancients has never been entirely laid aside. Thelden, for example, carried
a ligature round the pedicle of the polypus, by means of a forceps forming by
the union of its blades a ring indented on its convexity and pierced with an
eye at each of its free extremities ; after which he used this thread for the
extraction of the tumor. Though Vogel succeeded with the forceps of The-
den, Sir A. Cooper, who, when he can, also extracts polypi with the ligature,
thinks proper to reject its use, the actual necessity of which no one will pre-
tend to maintain. Admitting that this mode of extraction, as Sir A. Cooper
asserts, has the advantage^of being less liable to hemorrhage, and of bringing
OPERATIVE SURGERY. 439
away at once the whole root of the polypus and the fibro-mucous mem-
brane which gives it origin, it is yet subject to the serious disadvantage cf
requiring two operations instead of one, of not being applicable to hard and
pedunculous polypi, and of being with difficulty employed in the depth of the
nostrils. When the tumor is not larger than a walnut, when it is firm without
too thick a pedicle, the following manoeuvre may be practised, as it was done
by Morand, with success. The two index fingers are introduced into the nose,
one in front the other from behind, as far as the polypus, which is moved
alternately towards the pharynx and the face until finally detached, when it
is brought out through the passage that offers the least resistance. This is a
process which, in imitation of M. Dupuytren, it would be well to combine with
the use of the forceps. Undoubtedly, by pressing on the tumor with the finger
through the pharyngeal opening of the nasal fossa, extraction with the forceps,
which draws it in the opposite direction, is more certain and easy.
Operation. — Extraction requires no preparation, unless it has been thought
fit to imitate G. de Salicet in enlarging gradually the anterior opening of the
nostrils with a sponge, or any other dilatory means. Cold water, vinegar and
water, one or more basins, a cloth and napkins, charpie, and all the apparatus
directed for plugging the nasal fossae, a hook, scissors, a probe-pointed
bistoury, an ordinary bistoury, Museux's forceps, and several polypus forceps,
as they may become necessary, should be arranged on a table or large salver.
It would also be well to have ready dossils of lint sprinkled with rosin, and
even one or two cauteries, in case of obstinate hemorrhage. The patient is to
be covered with a cloth with his face towards a window in a good light, and
his head held by an assistant. If an adult, he may have his hands free,
in order to be able to gargle at pleasure ; but wrapped round and concealed
by the cloth, if a child. Standing in front, the operator introduces his forceps
into the orifice of the nose; ascertains with this instrument the precise seat of
the polypus which he grasps as near its pedicle as possible, taking care
also to embrace it very extensively ; he then draws it gently towards him ; takes
hold again a little higher up, if it elongates, with a second forceps without
loosino; the first, and still with a third, if he is fearful of not removino; its root,
and then tries to extract it entire at a single jerk. When the tumor is too
deeply situated, and not extensible enough to protrude outwards before being
torn, it would be better as soon as it is grasped to turn the forceps steadily on
itself, continuing to draw until the polypus yields and is detached. During
these efforts the instrument is held by its ring in the right hand and near its
crossing with the left, in order the better to direct its movements, and in
some cases to make it act as a lever of the first kind, by inclining its blades
with all necessary force above, inwards, and outwards. If the whole tumor is
not at first extirpated, or if several exist, the operation is recommenced imme-
diately and always in the 'same manner, until there is a certainty that no
foreign body is left in the nasal fossa. On this point when we wish to
discover if such exist, when the eye discovers nothing more, it is sufficient to
make the patient breathe strongly through the diseased nostril, the sound one
being kept closed. As long as there is difficulty in the passage of the air, we
may be sure thai some portion of the polypus has escaped the action of
the forceps. But if nothing arrest it; if it arrive freely at the respi-
ratory passage, it is unnecessary to examine further: the operation is
finished.
440 NEW ELEMITNTS OF '
Remarks. — Mucous polypi are too soft, and too easily adapt themselves
to the parts which surround them for the narrowness of the opening, to offer
any serious obstruction to their extraction. With hard polypi it is otherwise.
The irregularities with which they are covered, to adapt them to the form of
the meatus ; the elongations which they sometimes send out behind, before, or
in the maxillary sinus; or, as I once saw with the zygomatic fossa, throu«>;h the
spheno-palatine foramina, of which also M, Blandin gives an example, render
it very difficult to draw them out. As in the body of the nostril the bones do
not oppose to them a very powerful resistance, they depress them, push the
septum to one side, and the spongy bones and the ethmoid to tlie other,
and depress the palatine vault without much difficulty, while posteriorly the
pterygoid apophysis, the body of the sphenoid and the thick edge of the
vomer, oppose a much more considerable obstacle, and in front the nasal
process of the maxillary bone retains them also for a longer or shorter time.
They are especially restrained by the ring or fibro-cartilaginous collar of the
facial orifice of the nostril. In consequence of its great elasticity, this circle
tends continually to return within its natural limits, and resists infinitely
better than bone the efforts made against it. If it seem too laborious to
extract a large polypus, rather than employ the dilatation of G. de Salicet, we
should make an incision from the free edge of the ala of the nose to the trian-
gular cartilage, as advised by M. Dupuytren. When the tumor protrudes
from the posterior aperture of the nasal fossae, it is rarely possible to extract
it entire through the nose. In this case the curved forceps become indis-
pensable for seizing it through the pharynx above the velum palati. If in this
position it has acquired a large size, or if in consequence of a particular dis-
position it forces downwards and forwards the posterior half of the palatine
vault to the point of contracting the isthmus of the fauces, the method of
Manne or of Nessi, which consists in dividing the velum palati with a curved
bistoury from above downwards, 'should not be rejected. Heuermann and
Morand have given it their approbation, and I have myself tested it in a simi-
lar case; and its condemnation by Schumacher only proves that it was not
indispensable in the case he mentions. It is a true unbridling, which is
performed without danger of wounding any artery of considerable size. The
polypus, which may then be grasped and extracted, if not entire at least piece-,
meal, with the forceps or the fingers, may also be excised with curved scissors,
or the cutting forceps of M. A. Severin. There are cases, moreover, in which
these several operations are to be united and skilfully combined; in which,
after extracting a great portion of the tumor through the nose, and another
through the pharynx, as in a case reported by M.Chaumet, in 1821, whether
unbridled or not anteriorly and posteriorly, enough of it remains for the appli-
cation of the process of Morand. In every case the patient should be
permitted from time to time to wash his mouth and nose with cold water, pure
or acidulated. If hemorrhage should become too abundant, the operation
should cease, and further attempt delayed for several days. When it does not
cease spontaneously plugging should be resorted to, which almost always
renders the application of caustics or the hot iron unnecessary. Tiiese should
only be had recourse to after vainly trying inspirations of I'eau de Rabel, a
solution of alum, or some other styptic.
Reaidts. — The extraction of polypi is rarely followed by serious accidents.
Scarcely any fever supervenes if the patient follows a strict course of diet for
OPERATIVE SURGERY. 441
several days. It is a method, however, which is far from succeeding always,
or from being employed with advantage under all circumstances. It is parti-
cularly proper for mucous and fibrous polypi with a single root, and for all,
the base of which is not extended over too large a surface; in a word, for
those tliat may be extracted entire. Sarcomatous polypi, in v/hich the can-
cerous degeneracy commences at the projecting part, will admit of it, if, as
M. Dupuytren maintains, they can be distinguished from others before pro-
ceeding to the operation ; but, in other cases, says M. Boyer, it will only
hasten tlie march of symptoms, and conduce to formidable changes. Here, more
than in any other case, the operator should call to mind the anatomical dispo-
sition of the nasal cavities, so as not to grasp and tear out, instead of polypi,
the turbinated bones which are on the outer side, nor bruise the septum which
is within, nor the cribriform plate of the ethmoid which is above, nor to mis-
take a simple swelling of the mucous membrane, or any deviation of the
bones for an abnormal production, so as to go astray in any stage of the
operation ; but to carry his forceps in the proper direction, so as to know that
tumors may exist in the nose which have their rise in the frontul sinus, as on
the patient operated upon by M. Hoffmann ; in the maxillary sinus, and even,
in the interior of the cranium, or in the pterygo-maxillary fossa, for example,
as in the subject mentioned by M. Del Greco, who had the superior maxillary
nerve transformed into five enormous polypoid masses.
6. Ligature. — Like most of tlie preceding methods, tlie ligature may be
referred to the highest antiquity. Nevertheless, the Greeks and the Arabians
hardly proposed it but as accessary to excision or extraction. We must
come down to the sixteenth and seventeenth centuries, to find it clearly
described and formally indicated. Fallopius performed it with a brass wire,
the noose of which he carried round the polypus wdth a silver canula. F. de
Hilden says nothing of his process. Glandorp, who particularly mentions it,
practised it with a kind of needle in the form of a hook, having an eye near
its point which carried a silk cord. In the course of the last century, it
became the subject of numerous researches and modifications.
a. First Process of Levret. — Levret proposed to carry a silver wire by
means of a probe around the root of the tumor, and then pass its two ends
through a double canula, so as to be able to twist them by turning it on its
axis, after fixing them to the rings at its free extremity. Instead of two tubes,
soldered side by side in the form of a double sound, Palucci is said to have
invented a single canula like that of Fallopius, but divided by a small trans-
verse piece at its nasal extremity. Levret himself used this instrument, and
had made it known before it was mentioned by Palucci. It is neither more
nor less convenient than the preceding, of which it may be considered a simple
varietv. The same may be said of the instruments of Nessi, Hunter, and
King;
b. Second Process. — Unable to reach polypi of the posterior nares with his
double canula, Levret had constructed for this purpose a kind of forceps with
rings, a porte-ligature forceps with long branches, curved inwards a little and
swelling into a bulb at the extremity and hollow^ which surgeons have not
adopted more than that of Theden, which, without doubt suo;gested the idea.
c. Process of Bras dor. — The difficult point in the first process of Levret is
to engage the polypus within the noose carried by the metallic tube. Brasdor
5Q
442 NEW ELEMENTS OF
thought to remedy this inconvenience by drawing through a silver.wire doubled
to form a noose, as the dossils of lint are drawn forwards from behind in
plugging the nasal fossae. The two extremities being brought through the nose,
the surgeon with one hand draws them gently forwards, while, with two fingers
of the other carried in the pharynx, he endeavors to direct the noose over the
root of the polypus, then introduces them into a serre-nceudy and immediately
proceeds to the strangulation of the tumor. A simple thread is, besides, fixed
to the middle portion of the silver wire, and left free in the mouth in order to
draw back the ligature, to replace it if not properly applied at first. This is
an improvement, it must be confessed ; but as metallic ligatures cannot be
tightened but by twisting them upon themselves, and as, consequently, they
often break before cutting through the pedicle of the tumor, many prefer a
hempen, flaxen, or silken ligature. The sole advantage not to be denied them
is that of forming a noose, which is easily kept open without twisting.
d. Process of Desault. — Reasoning from this hypothesis, Desault at first
used a ligature of thread instead of the silver wire of Brasdor. Afterwards,
to obviate the difficulty of forcing the tumor within so flexible a ligature, he
employed another method. His last process is performed by means of three
separate instruments ; first, a canula slightly curved, terminating in a bulb
and furnished with a lateral ring at the other extremity ; second, a wire of
iron or steel, a kind of porte-nceiid which slides easily in a second canula,
and when open represents a forceps, but when shut its beak forms a ring ;
third, a serre-noeud, another metallic shaft, one extremity of which being bent
at a right angle with its axis, has a circular opening, while the other is bifur-
cated . One half of the thread is fastened to the ring of the canula after passing
through it ; the other is passed through the ring of the porte-fil-forceps which
is then closed by drawing it within the sheath. The surgeon then introduces
both instruments together as far as the polypus, and even a little beyond,
guided by the floor or septum of the nasal fossae, that is, the part of those
cavities which is the least embarrassed, and endeavors to place them above or
below, at the right or the left of the pedicle of the tumor ; holds the porte-
nocud at this point with the left hand, while with the other he causes the canula
to glide over the whole circumference of the tumor, and brings it to a point
diametrically opposite, so as exactly to embrace its pedicle ; passes the canula^
and the porte-noeud once or twice about each other, in order to form a circle
of the noose of thread, and withdraws the instruments, leaving the ligature
in its place; passes its ends through the ring of the serre-noeud, which he
pushes backwards with more or less force for the purpose of strangulating the
morbid mass ; then fixes the extremity of the thread upon the bifurcation, and
attaches it to the cap of the patient to keep the whole within the nasal fossae.
Constriction is increased gradually by drawing each time with greater force upon
the serre-noeud, and in a few days the extrication of the polypus is complete.
Anotlier process of Desault, less embarrassing than the preceding, consists in
carrying the loop of a long thread through the nostril, as far as the pharynx, by
means of a gum-elastic sound or a bougie. The operator seizes this loop with
his finger as soon as it appears behind the velum palati ; brings it through the
mouth ; detaches from it the conducting sound, which he withdraws through
the nose ; fixes to it a common thread designed for the same use as in the pro-
cess of Brasdor; draws it back through the back part of the mouth, supporting
OPERATIVE SURGERY. 44S
it with two fingers, while an assistant draws its two extremities through the
anterior aperture of the nose; after which they are engaged in the serra-nocud,
as before. If the fingers are not long enough to follow the noose to the poste-
rior opening of the nares, two threads instead of one, fastened to the ligature
an inch apart and then passed each through a canula, will supply their place
very advantageously. This process was further modified by Desault himself,
for the special purpose of applying it more easily to polypi of the pharynx.
Having introduced the extremity of a ligature, and the two ends of a loop of
thread of a different color from the mouth and throat, and brought tliem out
by the nasal fossae, he engaged in his slightly curved canula the extremity
remaining in the mouth, penetrated with this canula to the bottom of the pha-
rynx, and employed it for passing the ligature around the polypus; then
slipped over it the noose of the accessory thread which an assistant was charged
with drawing through the nostril, for the purpose of bringing through this
passage the second end of the ligature, which is then passed with the first
through the ordinary serre-noeud.
e. Process of M. Boyer. — M. Boyer, who approves of these different methods
and has tried the greater part of them with success, has found it best under
some circumstances to substitute a catgut for the lio;ature of thread recom-
mended by Desault.
/. Process of M. Dubois. — With the view of preventing a collapse of the
noose of the ligature before reaching the root of the polypus, M. Dubois for-
merly recommended it to be enclosed in a piece of elastic sound about three
inches long, which may be afterwards drawn through the nose by tractions
made as if for turning the ligature over a pulley, by acting for a moment on
one of its extremities only. This little tube being removed, the other end is
drawn so as to bring them even, and both are then passed into the serre-noeud.
Unfortunately this piece of sound does not always follow the direction in-
tended to be given to it. It slips sometimes to one side and sometimes to the
other, and often is of more hindrance than service, so that means are still to
be sought for, to keep open the loop of thread as far as the top of the pharynx.
g. Process of M. Rigaud. — In the month of January, 1829, two new in-
struments were proposed for this purpose. One named by its inventor, M,
Rigaud, a polyodome, is composed of three branches of steel, capable of
moving, of advancing, and retiring separately or together, in a strong canula.
Bent into an arch at their extremities, they form a kind of forceps with three
branches, which are opened and closed at pleasure. The extremity of each
has a bird's-eye or opening continuous with a small fissure which seems to
bifurcate them. The middle of the thread is fixed in these openings, and the
ends are carried through the nose by the sound of Bellocq. The forceps,
with its three branches closed, is then carried into the back part of the mouth,
and are there separated more or less according to the size it is necessary to
give the noose. Then the end of the instrument is elevated as much as pos-
sible by inclining it towards the nasal fossae, and sometimes a little to one side,
as in using the polypus forceps. To disengage the thread it is sufficient to
draw with some force upon the ends which hang out of the nose. The two
halves of their terminal fissure being; elastic enough to hold the thread when
not drawn upon, easily let them escape upon the pedicle of the tumor. What
remains has nothing peculiar.
444 NEW ELEMENTS OF
h. Process of M. Felix Hatin. — The other, that of M. Felix Hatin, is a plate
of polished metal bent almost to a right angle near its pharyngeal extremity,
arched and rounded on its convex surface and chiefly at its vertical portion,
and may serve two purposes and answer two indications. Its horizontal
portion depresses the tongue very well, while the other obliges the ligature to
glide over it until it reach the polypus. It is a very simple instrument wliich
might be supplied in reality by a table-spoon bent forwards near the base of
its handle. But the polyodome of M. Rigaud is incontestibly preferable, as
it occupies less space, conceals the parts less,, and carries the ligature more,
surely where, and as we wish; and besides it can conduct it with advantage
without passing through the mouth upon polypi of the anterior portion of the
nasal cavities.
JRemarks. — The serre-noeud has attracted the attention of a great number
of practitioners. Bichat directed it to be divided so that withoijt being dis-
placed it might be made longer or shorter as occasion required. That of M.
Graefe is composed of two pieces, which slide one on the other by means of a
lateral button, which permits powerful strangulation of the polypus without
deranging the extremity of the threads. But the most ingenious of all is that
which Roderick, a wealthy individual of Cologne, had constructed to cure
himself of a polypus which had defied all the eftbrts of the surgeons of Brus-
sels. It consists in passing the two extremities of the thread brought through
the nose through a series of small ivory balls, and then fixing them on a tour-
niquet or little roller. The chaplet which is thus formed adapts itself per-
fectly to the different curvatures of the nasal fossie, and causes incomparably
less inconvenience by its presence than any other. To increase the constric-
tion of the polypus, it was only necessary to shorten this little chain by turn-
ing the roller or tourniquet. The balls may be made of wood, bone, or metal.
M. Sauter had them made of the tips of ox-horns. M. Mayor, of Lausanne,
ordered them of silver, tin, &c., and employed them upon polypi, as has been
said above in the article Tongue. In fine, instead of the axle, M. Bouchet,
of Lyons, used a little barrel, while M. Levanier employed only a simple
catch. M. Braun has also thought proper to modify this instrument, previously-
hinted at by Girault or Riolan, which the serre-noeud of Desault most fre-
quently renders useless, but which in some cases may become valuable.
The process described by Dionis is reduced to carrying with a crow-bill
forceps a sliding knot over the pedicle of the tumor, one of the ends of which
is then passed through the nostril with a long needle of lead or brass, and
brought through the mouth, while the other remains at the extremity of the
nose. It is scarcely ever practicable. That of Glandorp, modified by Gorter,
renewed by Heister, who used with success for applying the ligature in a
woman seventy years old a bent needle fixed in a handle, with an eye near its
point (very similar to the needle invented by Goulard for tying the intercostal
artery), cannot be reasonably tried except in cases where the polypus is very
near the aperture of the nostril. Admitting for a moment that it may be pro-
perly fixed over the tumor, this species of ligature presents still an incon-
venience which the ancients seem not to have noticed. As the anterior nasal
opening descends below the palatine floor of the nostrils, the cord necessarily
presses with force on the facial edge of this floor when it is drawn through the
nose, and continually tends to cut or at least to excoriate it. To remedy this
OPERATIVE SURGERY. 445
Levret proposed to add a handle to the two ends of the seton, which he some-
times advised to be used. For the same end M. Felix Hatin recently proposed
a small plate to be held vertically behind the lobe of the nose, where it is to
act as a return pulley and may be made indifferently of metal, ivory, horn, &c.,
and for which a staff of steel, pierced superiorly with an eye for the passage of
the thread, will be a perfect substitute. On the whole, the ligature is not proper
for polypi with a large base, nor vesicular polypi. In whatever manner it may
be applied, it should be tightened every day until the body it embraces shall
fall off. The avowed intention is to produce mortification of the polypus by
intercepting the course of the fluids in its pedicle, which it should at last
completely divide. Consequently we must expect to see the tumor swell
immediately after the operation, and then to become shrivelled or decomposed,
and require the use of forceps or hooks when its root is detached. On the
other hand, injections of acetated or alum water, or some styptic or antiseptic
solution, forms in this case an accessary not to be neglected. Prudence also
requires that the patient should keep himself inclined forwards, so that the
putrid matters may not descend into the digestive passages. If the polypus
is to fall into the pharynx, it will be important previously to pass a thread
through it by means of a needle; otherwise it might be directed towardsthe
opening of the larynx after being detached, and cause danger of suffocation,
x^fter it comes away it is well to continue the use of detersive, astringent, or
styptic injections for a week or two, if the nostril has not entirely ceased to
suppurate. Having pointed out, in discussing these several methods, the merit
of each in particular, it is unnecessary here to bring them in comparison to
determine 'their relative value. As no single one can obtain an absolute pre-
ference, the choice of the process to be used in each individual case must be
left to the sagacity of the surgeon.
Art, ^,-^Maxillary Sirms^
§ 1. Perforation.
The maxillary sinus or antrum highmorianum, is often the seat of diseases
for which perforation has frequently been performed. Worms, which Borde-
nave, Fortassin, Heysham, &c., say have been found there, would without doubt
require it, if it were possible to recognize their existence during the life of
the patient : so also with the small bodies of adipocire which it has been
remarked are sometimes formed in it ; but recourse is especially to be had to
perforation, to remedy abscess, dropsy, ulcerations, fungus, fibrous and car-
cinomatous tumors, polypus, necrosis, and caries of this cavity. Jourdain, who
about the middle of the last century insisted so much on the advantages of
medicinal injections through the natural opening of the sinus, and on the use-
lessness of its perforation in almost all its affections, has not succeeded, not-
withstanding the numerous reasons he advances in convincing practitioners ;
and at the present day his doctrine has no defenders. On the one hand, it is
most frequently found to be very difficult, whatever may be said, to discover
with a probe the enti-ance to the sinus in the centre of the middle meatus of
the nasal fossae ; on the other, this opening, more frequently obliterated by
disease than in any other manner, would afford no relief even should it be
446 NEW ELEMENTS OF
re-established ; and taking every thing into consideration, artificial perfora-
tion, being less difficult and more certain, ought to be preferred.
1st. Method of Meibomius. — Of the various modes of effecting this perfora-
tion, the most ancient is not, as generally believed, that which consists in
penetrating into the cavity of the maxillary bone through the sockets of the
molar teeth. Molinetti, who wrote in 1675, says, that in a patient who was
a prey to horrible pains, a crucial incision was made in the cheek, and the
antrum highmorianum, which was the seat of an abscess, was penetrated with
the crown of a trephine. It is wrong, morover, to give the honor of it to Mei-
bomius, Zwinger a long time previously, after the extraction of several
loose, necrosed teeth, healed a caries of the maxillary bone, by dilating the
diseased socket with prepared sponge. Ruysch remarks, that Vanuessen
destroyed a polypus only after extracting several molar teeth and cauterizing
their sockets with red-hot iron, so as to admit the finger into the maxillary
sinus. Some years afterwards, in 1697, W. Cowper, according to Drake,
who formally consulted him, preferred the socket of the first molar tooth,
and penetrated the sinus with a kind of punch, so as to be able to inject
liquids. Meibomius, whose researches were published in 1718, so far from
having invented this method, confined himself to the extraction of a single
tooth, to give issue to matter accumulated in the sinus, the perforation of
which appeared to him to be altogether dangerous. This was also the prac-
tice followed by Saint Yves with success upon a patient who had an old
fistula, attended with destruction of the floor of the orbit ; so that it was
necessary for Cheselden to introduce it again, to attract the attention of prac-
titioners^ This surgeon preferred the extraction of the third, and even of the
fourth tooth to that of the first or second, as laid down by Junker; and in case
of an osseous fistula, to enlarge it instead of piercing the bottom of the socket.
Since that period, it has been modified by different authors. Heuerman, who
also prefers the socket of one of the last teeth, recommends, if the pus does
not immediately escape, to perforate the sinus with a stylet, and to place a
little canula in the opening, in order to prevent its too speedy obliteration.
Bordenave judiciously remarks, that with the exception of the first, all the
molar teeth correspond to the maxillary sinus ; and consequently, if one be
carious or more painful than the rest, that should be removed in preference,
but that the third should be extracted if all be equally sound. He prescribes,
on the other hand, the extraction of all that are decayed, provided they are
nx> longer of service. A canula of lead, in his opinion, is more proper than
sounds and bougies to keep the orifice open for some length of time ; and he
does not think, after all, that the process should be the same in every case.
Desault, who adopted the principles of Bordenave, commenced the operation
with a trepan mounted on a swelling handle, and terminated it with another
instrument of the same kind but with a blunt end, so as not to wound the
opposite wall of the sinus. According to B. Bell, if there is a choice, one of
the posterior teeth should be extracted, and in the interval between the dress-
ings the orifice should be kept closed with a plug of wood. Richter perforates
the socket with a trocar. He forbids the canula which is placed in it to be
left open, because particles of food might be introduced through it into the
sinus. Deschamps prescribes a permanent canula to be fastened to one of
the teeth by a thread. The method of Meibomius, which offers the advantage
OPERATIVE SURGERY. 447
of placing the opening in the most depending point of the sinus and of leaving
no external cicatrix, the execution of which is besides simple and easy, and
preferable to all others when there is a carious tooth, should yet be rejected
in the contrary case, and also when the alveoli, having long been deprived of
their processes, are entirely closed.
2. Method of Lamorier. — In this case, Lamorier, a surgeon of Montpellier,
recommends the penetration of the maxillary sinus immediately below the
zygomatic process, between the malar bone and the third molar tooth. This
point corresponds with the summit of the cavity, and its parietes there present
the least thickness, and it is there more easily reached. An assistant with a
blunt hook draws the labial angle outwards and upwards. The operator
incises the fibro-mucous membrane which covers the bone at the bottom of
the maxillo-labial sulcus, and on the designated point, with a scalpel or good
bistoury, traverses the osseous wall with a strong punch, enlarges the opening
as much as he judges necessary, and concludes by inserting into it a tent of
charpie.
3. Method of Molinetti. — Others, returning to the operation of Molinetti,
have advised the division of the cheek first between the malar bone and the
infra-orbitary foramen, and then penetrating from this wound into the interior
of the sinus; but unless imperatively demanded by the circumstances, the
division of the external soft parts ought to be avoided.
4. Method of Desault. — Here Desault prescribes entrance into the maxil-
lary sinus through the canine fossa, piercing beneath the superior lip. Instead
of the perforators, one sharp and triangular and the other blunt, invented by
Desault for this species of operation, Runge,who practised in 1740, employed
simply a scalpel, which he turned four or five times on its axis to enlarge its
first opening. The trephine, which Charles Bell designed for the same purpose,
has neither greater nor less disadvantages than the scalpel of Runge, or the
perforating trepan of Desault.
5. Method of Gooch. — Upon a patient who had no molar teeth, Gooch con-
ceived the idea of perforating the antrum highmorianum through its nasal
surface, and fixing there a leaden canula. 01. Acrel had already followed
a process nearly similar ; that is, after operating in the manner of Cowper, he
placed a second canula in the sinus through the nose, which presented there a
fistulous opening.
6. Method of RuffeL — A buccal fistula of the maxillary sinus suggested to
Ruifel the idea of inserting there a trocar, and bringing it out above the gum
to establish a counter- opening. A seton was then passed and kept in this
passage for six weeks, when success crowned the efforts of the surgeon.
7. Method of Callisen. — Callisen, who adopted the seton of Ruffel, and was
followed in tliis particular by Zang, thinks, with reason, if fluctuation is per-
ceived at the palate vault, that the artificial opening ought to be there
established. Busch and Henkel have fully succeeded by means of a seton
introduced through a fistula of the floor of the orbit, and brought into the
mouth through an opening in the alveoli. Bertrandi did the same, except that
he omitted the use of the seton with a patient who could not open his mouth,
and who had also a fistula at the orbitary wall of the sinus.
8. Method of Weinhold. — In the process which the Germans attribute
to Weinhold, the surgeon first carries his instrument to the superior and
448 NEW ELEMENTS OF
external part of the canine fossa, and directs it obliquely downwards and
outwards, avoiding carefully the branches of the infra-orbital nerve ; per-
forates the sinus, and then fixes a dossil of lint in the wound. If the sinus
has no other issue, Weinhold directs it to be perforated through and through,
either by pushing his first instrument into the mouth through the palate vault,
or by a curved needle when he means to place the counter-opening without
the gum and above the alveoli. An eye, which is found in both instruments,
permits a thread to be drawn at the same time through the sinus, conducting
a roll of lint designed to perform the oflice of a seton, which is covered with
some appropriate medicament. This method approaches nearly that of Ruffel
or of Henkel, and may be tried as well as that of Desault or Lamorier. It
resembles also that of Nessi, who, after having largely opened the sinus
through the mouth, inserts a trocar and destroys as much as possible of the
anterior wall below the malar bone or the canine fossa.
Remarks, — On the whole, perforation into the maxillary sinus is performed
in the point of election or of necessity. The first may vary according to the
ideas of the operator. The circumstances, on the contrary, determine the
second. In case of abscess, dropsy, fistulas, and ulcerations, the operation is
almost always performed in the place of election. Then, provided one of the
molar teeth be unsound, it must be extracted, together with the adjoining
tooth ; the gum is then to be cut down to the bone, externally, internally,
behind, and before, forming a kind of square flap, and to be completely de-
tached from the surrounding tissues ; after this, the alveoli are to be perforated
with the instruments of Desault, and an opening made large enough to admit
the finger into the sinus. M. Boyer, who follows this process, insists with
reason on the necessity of giving this opening considerable dimensions. If
all the teeth are perfectly sound, or if the patient has lost them a long time
before, and the alveolar margin is round and full, preserving its natural
firmness, the method of Desault or Lamorier, in my opinion, deserves the
preference. Supposing that it does not succeed, there will always be time
to have recourse to that of Meibomius, which, it cannot be denied, is incom-
parably more painful and terrifying to the patient.
§ 2. Foreign Bodies ; Polypi,
Simple extraction of a foreign body, a ball, shot, or splinters of bone, for
example, must be effected through the anterior wall of the sinus. When a
polypus, a fungus, or a necrosis, on the contrary, is to be removed, reason
requires that we should attack it at the point to which it seems naturally
to tend, or which has sustained the greatest alteration. Thus it sufiiced
Dubertrand, in extirpating a polypus of this description, to unite the two
alveoli by breaking down the division between them, and removing the frag-
ments of carious bone ; while Caumont was obliged, in a patient who had
fruitlessly submitted to a similar operation, to reach the tumor through the
canine fossa where it showed itself; and again, it was necessary in the case
cited by Chastenet, to destroy nearly half of the maxillary bone with its pala-
tine process to accomplish the same purpose. When the antrum highmorianum
is opened for the sole intention of giving free issue to the matters it secretes
or exhales, the sequel of the operation is reduced to simply detersive, astrin-
OPERATIVE SURGERY. 449
gent, antiseptic, or dessiccative injections, until the bottom of the wound is
covered with cellular granulations of a good red color. If, at the same time
any necrosed osseous portions exist, they are to be removed. In this case it
is often necessary to prolong the incisions, enlarge the opening, and have
recourse to the saw, scissors, cutting nippers, or the gouge and mallet. The
same occurs in case of exostosis, and every other alteration of the osseous
tissue. When the sinus contains a polypus, the tumor is treated as if it were
in the nose ; with this difference, that extraction, which is generally applicable,
rarely fails of being sufficient, and it cannot be seen at least what advantage
is here presented by the ligature. After its periphery has been isolated, and
its pedicle or base displayed, it is grasped with polypus forceps, or, if found
more convenient, with the forceps of Museux, which has been frequently used
by Dupuytren. It is then extracted by pulling, or rather by twisting it upon
itself. If it has not sufficient density to resist the grasp of the forceps, it is
removed by incision after making it yield as much as possible ; and if any
osseous bands or lamellae prevent its extraction, they are to be divided with-
out hesitation, at least whenever there is no danger in touching them. When
it has more breadth than prominence, or when instead of polypus we meet
with fungi or any other degeneration, we are sometimes obliged to remove
piece by piece w^ith the common or probe-pointed bistoury, or a scalpel with a
truncated point, short, wide, a little bent on the side like the knife of F. de
Hilden, devised by Pelletan, and approved by M. Boyer ; or, in fine, with any
other appropriate instrument ; a kind of cutting spoon, like that of Bartisch, for
instance, which is sometimes employed by M. Dupuytren. On the other
hand, if the tumor be too voluminous for easy extraction through the maxillo-
labial fissure, we must incise boldly the whole depth of the lip or one of its
commissures, in the most suitable direction. The twisted suture renders
union of this wound so easy, that it would be truly culpable to neglect it
whenever the operation would be simplified by its use. Caustics may be
applied to destroy what could not be removed by extraction and excision.
Mineral acids, butter of antimony, and better than all, the acid nitrate of
mercury applied by means of fdrceps, and retained by dossils of lint, have the
advantage of not transmitting far their action, as does the actual cautery,
which in this point in particular is to be dreaded on account of the vicinity of
the eye. However, it is to be remembered, that Garengeot only succeeded in
destroying a fungous mass of the antrum maxillare, by consuming it with red-
hot iron, after it had resisted repeated excision, extraction, and chemical
escharotics. The nitrate of silver, alum, sulphate of iron or copper, and every
substance rather styptic than really caustic, are not adapted in truth but to
vegetations, small ulcers, and swellings; in a word, to alterations uncon-
nected with the bones and exhibiting none of the character of malignity. It
need not be said that if a misplaced tooth be the cause of the disorder, it
should be sought for and immediately extracted. The records of the art
contain facts extremely curious on this point; for example, the one pub-
lished by M. Dubois. Expecting to find a fungous tumor, this practitioner
saw only a turbid liquid matter flow from the maxillary sinus, into which he
had just made a large opening above the dental range. The wound soon
closed, but the tumor remained. With the assent of Messrs. Pelletan and
Boyer, &c., M. Dubois extracted three teeth, removed a large portion of the
57
450 NEW ELEMENTS OF
alveolar margin, and thus entirely brought to view the antrum ; he found no
fungus, but perceived at the top of the cavity in the substance of its anterior
wall a whitish projection, which was nothing but a tooth, an incisor, whose
root was found rivetted as it were in the sinus. As to hemorrhage, these
several manoeuvres sometimes render it so abundant, as to require the opera-
tion to be temporarily suspended. If it does not stop spontaneously, eau-
de-Rabel, vinegar and water, or plugging with balls of charpie springled with
rosin, and even on emergency heated iron, are at the disposal of the surgeon,
and always aiford an efficacious remedy.
Art. 3. — Frontal Sinus; Perforation,
The direct communication of the frontal sinus with the middle meatus of
the nasal fossae, renders the perforation of them rarely indispensable. The
polj'pi which are sometimes developed there, soon extend into the nose, where
they may be reached with the forceps as well as if they sprung from any other
point of the nostril. Heister is said to have extracted them by this passage.
Pus, glaiy mucus, sebaceous and fibrinous concretions, and worms, have all
been found in them, but less frequently than in the maxillary sinus ; yet it is
rare that these substances accumulate there in any quantity, and do not find
issue through the nose. The perforation of the frontal sinus is therefore
really indicated but under very few circumstances. Without being difficult
or delicate, its execution nevertheless requires some important precautions
which are not to be neglected. Thus, in order to strike as low as possible
upon the frontal cavity, it will be proper, in my opinion, to lay bare the bone
between the supra-orbitary foramen and the root of the nose. Then the
small crown of the trepan, or Desault's instrument for the maxillary sinus, is
to be directed obliquely backwards, upwards, and inwards. Through this
opening, more or less enlarged with forceps, a hook, crotchet, or scissors, we
are to seek for the tumor or the foreign bodies to be extracted ; apply a tent
simple or medicated to the disease ; make injections and introduce caustics, or
even the hot iron if necessary. The air which penetrates freely from the
opening of the frontal sinus through the nose, and vice versa, seems at first
view to become an insurmountable obstacle to artificial cicatrization, and to
convert it almost necessarily into a fistula. This has been observed more
tlian once; and M. Dupu}'tren and some other practitiojiers look upon it as
tiie constant result. But we have at present sufficient proof of the contrary,
so that we need not hesitate on account of this opinion. Wounds of the
frontal sinus close quite as well as those of the antrum highmorianum, and
their chief inconvenience consists in leaving indelible cicatrices on one of the
most striking parts of the countenance
Section v.
The P'ace.
Art. 1. — Osseous Cysts.
Tumors filled with turbid serosity, as in ranula; or of a fibrous, fatty, or
fungous nature; or even composed of several of these elements at once, have
often been observed without the maxillary sinus, and in the very substance of
OPERATIVE SURGERY. 451
the bones of the face. Rurige, who appears to be one of the first to notice
them, sajs that his father and himself had met with them in either jaw, and
that their point qJ[ departure is often from the summit of a dental root. It is
probable also, that those pretended lymphatic congestions, the parietes of
which were as thin as parchment, which Kirkland locates in the antrum high-
morianum, belonged to the same kind of affection. Did notCallisen fall into
the same error when speaking of tumors with separate compartments, which
according to him required the extraction of several teeth ? Siebold, who saw
an osteo-sarcoma between the laminae of the sinus, made section of it without
causing pain, and cured his patient; and has distinguished better than his
predecessors the special position of the disease. Runge, who besides de-
scribes it very well, did not let the fact escape that upon pressure with the
finger it recedes returning immediately afterwards to its place tvith iioise,
ranks it among the affections of the sinus. Sprengel accuses him of using
several times in his dissertation, inadvertently, no doubt, the inferior jaw for
the superior jaw. In this the learned historiographer is evidently mistaken.
It is certainly the inferior jaw that Runge means when he speaks of it. Only
he uses improperly the term sinus, in designating tumors which have their seat
without the cavities. These isolated facts had fixed no attention, and to M.
Dupuytren is the honor due of giving in his clinical lectures detailed notions
of the disorder here treated of. I have met with four cases. The two
patients from the vicinity of Tours, given by M. Fabre in La Clinique had
been submitted to my examination before being operated upon by M, Dupuy-
tren. Although without the sinuses, and observed more frequently on the
inferior than the superior jaw, and on the ramus as well as the body of the
bone, the tumor nevertheless nearly ahvays bears some relation to a diseased
state of the teeth. Similar in form and external appearance to carcinomatous
or fungous tumors, it differs from them essentially, in being more easily over-
come by art. Analogy leads to the opinion, that the various treatments
approved of in lesions of the maxillary sinus, would be usually applicable to
these ; and that by opening them on the internal face of the lips or cheeks,
when they are situated so as to admit of this operation, many of them would
disappear, so that it would be no great disadvantage to confound them with
polypus or other tumors developed in the antrum highmorianum, as happened
to the father of Runge, and, quite recently, to M. Dupuytren himself. But
until the present, at least, M. Dupuytren has found it sufficient to cut exten-
sively through the cheek, then make injections, and place every day a tent of
charpie in the wound, to produce its diminution and revolution.
Art, 2. — Section of the Facial Nerves.,
Neuralgia of the face, a cruel disorder, and characterized by the severest
pains, has often been subdued by division, cauterization, and excision of the
affected nervous trunk. It was natural to suppose, that by destroying tlie con-
tinuity of the sensitive cords, transmission of pain to the cerebrum would be
prevented, and the disease be thus completely removed. But as the nerves
are possessed of no power of retraction, it was to be feared on the other hand,
that after being divided they might immediately reunite, and therefore that
«imple division would not be followed by a lasting relief. Experience has
452 XEW ELEMENtS OF
unfortunately but too well confirmed these apprehensions. Hence the idea of
destroying enough of the nerves to render impossible the re-establishment of
their continuity, presented itself. Caustics or fire, proposed to fulfill this indi-
cation, have the serious disadvantage of producing large cicatrices, and horribly
disfiguring the patient. In our times the cutting instrument has been gene-
rally substituted in their place. By means of an incision in a line vi^ith the
corrugations of the skin, of the muscular fibres, or the principal vessels, they
may be exposed at their exit from the bones and cut, before sending oft* any
branches, and a portion two or three lines long removed. The wound, uniting
by the first intention, is unperceived after healing among the lines of the facCj
and the continuity of the nerve being forever destroyed, it seems impossible
that neuralgia should not be arrested by such powerful means. Nothing is
wanting on this point, but that clinical observation should never have contra-
dicted the theory. Often, too often, the disorder resists the best performed
excision as well as mere incision, and many patients have not been more
relieved by one of these operations than by the other, nor by the deepest
cauterization. At the hospital St. Antoine, in 1829, there was a man of about
forty-five years of age, who for fifteen years was afflicted with a tic douloureux,
and who submitted successively to section and excision of all the nerves of
the face, without any kind of benefit. However, as more fortunate results
have been published, when all other modes of treatment have been vainly
tried, especially when the suffering is extremely severe, it is a last resource to
propose to the patient, and of which perhaps it would be inhuman to deprive
him. The cords which may be subjected to it are four in number ; the frontal,
the infra -orbital, the inferior dental and the facial.
Frontal. — To derive all possible advantage from excision of the supra-orbital
nerve, it should be taken at the point, where, issuing from the supra- orbitary
foramen, it is reflected and passes over i\\Q bone before the origin of the
anastomosing branches which part from it to be united with the neighboring
nerves. Here it is only covered by the skin, a thin layer of cellular tissue, and
some pale fibres of the orbicularis muscle. The artery that accompa-
nies it is not of sufficient size to cause fear if wounded, and in the vicinity
no other organ is seen which can be exposed to the touch of the instrument*
If not distinguished at first sight through the integuments, it is only neces-
sary, for determining its location, to recollect that the fissure or canal which
gives it passage, is found at the union of the internal third with the external
two-thirds of the superior orbitary arch, or about an inch from the root of the
nose ; and by running the finger along the edge of the orbit from the nasal
apophysis to the temporal apophysis of the frontal bone, it is almost always
possible to determine its exact position.
The operator, placed behind the head of the patient, lifts the eyebrow with
his left hand, while the lids are depressed by an assistant; assures himself
anew of the place occupied by the diseased nerve ; takes a bistoury in his
right hand, holding it as a pen; applies its point upon the intenial orbitary
apophysis; brings it upwards, then outwards, and divides all the tissues down
to the bone to tlie extent of an inch, a little above and in the direction of the
adherent edge of the eye-lid ; separates gently the edges of this crescentic
wound; finishes the section of the nerve, if not already complete; takes hold
of ilA anterior end with a good dissecting forceps ; insulates it; and excises a
OPEIUTIVE SURGERY, 453
sufficient portion to prevent the subsequent re-establishment of continuity of its
two extremities. The immediate union of the integuments may be permitted
to take place. The loss of substance in the nerve gives, as far as that organ
is concerned, all security on this point. Yet, as the least infiltration of hete-
rogeneous fluid in the midst of lamellae so flexible, and tissues so easy of
separation as those of the eye-lids, the orbit, and the forehead, might induce
purulent collections and dangerous inflammation, it seems to me prudent, as a
general rule, to permit the wound to suppurate. It is therefore dressed lightly
with a pledget of lint spread with cerate ; or, if there be hemorrhage (but only
for the first time), with a little soft linen and rolls of charpie. No other care
is demanded than in simple wounds, and cicatrization soon takes place.
2d. Infra-orbital Nerve. — More deeply situated, surrounded by parts more
important, and spreading at its exit from the bone, the infra-orbital nerve,
is much less easy of excision than the preceding; but on the other hand,
it is much less subject to neuralgia. Two courses may be followed to reach
it. The first is through the mouth. Prolonging an inch upwards the furrow
in which the lip meets the jaw, we traverse the whole depth of the canine
fossa, and arrive at the root of the nerve, which is found in the direction of
the first molar tooth, three or four lines below the orbit. The bistoury, which
were necessary in the first, is to give place to straight scissors in the last
stage of the operation. Followed by M. Richerand, who even impinges on
the bone with his instrument, this method, the principal advantage of which
is to leave no traces on the countenance, only admits of simple division of the
cord, which should be excised. In the other, the instrument traverses from
the skin to the bone all the soft parts that compose the cheek, and hence it is
much more dreadful, at least to the fair sex. Fortunately, by following the
natural lines of the face instead of being governed exclusively by the direc-
tion of the fleshy fibres, it is possible to obtain a cicatrix scarcely perceptible.
Process. — The patient should be seated, dressed, and held as in all other
operations on the face. Armed with a straight bistoury, and placed in front,
the surgeon makes an incision at the bottom of the naso-jugal line, that is, of
the depression or line extending obliquely from the ala of the nose towards
the middle of the space which separates the prominence of the cheek from the
corresponding labial angle; in this direction then he makes an incision from
an inch to an inch and a half long, beginning at the external face of the
perpendicular apophysis of the maxillary bone, dividing at first but the skin ;
he then soon meets with the facial vein, which he pushes outwards, some fat,
and the proper elevator of the lips, which he pushes inwards, and the canine
muscle, which often conceals the nerve by its internal border ; he then uses a
steel director to put aside all these objects, tears the filaments and layers
which still conceal or may conceal the aflected nerve, cuts the nerve close to
the infra-orbitary foramen, removes a portion of it, and the operation is done.
3d. Inferior Dental Nerve. — ^The inferior maxillary nerve issues from the
jaw through the mental foramen below the osseous furrow, which separates
the alveoli of the canine and first molar tooth. This point is very easily reached .
While with one hand he inverts the lip outwards and downwards, the surgeon
with the other cuts through, layer by layer, from above downwards, with a
straight bistoury, the tissues at the bottom of the maxillo -labial sulcus. The
above mentioned teeth are his guides. At the depth of several lines he meets
454
Nr.W ELEMENTS OF
with the nerve ; insulates it to the extent of a quarter of an inch, bj separating
from the jaw the posterior face of the soft parts wliich cover it, and excises it,
following the course laid down for the frontal, and using no dressing.
An American surgeon. Dr. Warren, has been bold enough to seek for the
trunk of the maxillary nerve, and perform its excision in front of the pterygoid
muscles. A crucial incision of the skin, of the parotid gland, and masseter
muscle, allowed him to apply the crown of a trepan upon the coronoid pro-
cess, and seize the nerve with a stylet above the dental canal, and remove
about three lines of it with the scissors. The artery was woUnded, and
tied without difficulty. The patient, whom other excisions had temporarily
relieved but not cured, and who still experienced horrible pain, ceased to
suffer after the operation, and has continued well ever since. Ze vraipeut
71* ef re pas vraisemblabte.
4th. T7ie Facial. — Spread over almost every point of the face, the portio dura
of the seventh pair would at first seem to be more subject to facial neuralgia,
and therefore has been frequently excised. Its temporo-genal branch, the
only one which has been ventured upon, crosses the neck of the condyle of
tlie jaw at the place where the lobe of the ear is continuous with the integu-
ments of tlie face. At this point it is proper to expose it. An incision is made
a little oblique from before backwards or nearly Vertically, which, beginning
from the zygomatic process, terminates on the posterior edge of the jaw above
its angle. We must divide successively the cellulo-adipose layer, an aponeu-
rotic expansion, and several small prolongations of the parotid gland, before
finding the nerve, which is separated from the bone only by lamellated and
filamentous cellular tissue. In this way the temporal artery is avoided with
certainty; and if the transversalis faciei be wounded, it will be very easy to
compress it if the hemorrhage should prove troublesome. The other, the
cervico-facial branch, lost as it were in the parotid, presents too much anomaly
of position, and the trunk itself of the facial runs too deep and is surrounded by
too important parts, to let us think of its excision. An appeal ought to be
taken from this judgment, without rashness. I have assured myself frequently
on the dead subject, that the nerve now spoken of may be exposed without
danger at its exit from the cranium, before it has given off any other branches
tlian the mastoid, digastric, and stylo-hyoid filaments. For this purpose the
operator has but to make a vertical incision an inch and a half in length between
the mastoid process and the lobe of the ear, and keeping close to the anterior
face of the bony process and the corresponding margin of the sterno-mas-
toid muscle, to divide to the depth of from six to ten lines, the integuments,
the cellular expansion, and the parotid, which is to be drawn forwards. The
lips of the wound being separated, the nerve is to be see;i at the bottom, near
the middle of the space which separates the temporo -maxillary articulation
from the summit of the mastoid process, where it appears to direct itself to-
wards the edge of the inferior maxillary. The division and even the excision
of this nerve, is then as simple and as easy as that of the frontal ; and it is at
once evident, that this alone can offer all desirable guaranty in this case, pro-
vided these several excisions of the nerves be the temedy for facial neuralgia. I
raise purposely here some doubts of their value, because facts have not yet pro-
nounced conclusively in their favor. If in some cases they have been followed
by a marked diminution, or even a complete cessation of pain, they have
OJ»ERATIVE SURGERY. 455
been seen much more frequently to produce no relief or but a momentary
ease. I have already mentioned a man who had submitted to them all on both
sides of the face, without any appreciable advantage ; and M. Boyer has im-
parted to me a similar observation. The patient upon whom he excised, one
after the other, the four principal nerves of the face was at first slightly re-
lieved, but was not more Completely cured than he whom I have mentioned.
Moreover, if the opinions of Ch. Bell are correct ; if it is true that the frontal
infra-orbital mental ; in a word, all the branches of the fifth pair are exclusively
sensitive, while the seventh pair presides over only the muscular actions of
the face, it is evident that the division of the latter will only produce paralysis
of the muscles of the face, and it is only to that of the three others that we
are to look for what concerns neuralgia.
SECTION VI.
Auditory Apparatus.
^Srt. 1. — External Ear.
§ 1. Otoraphy.
Pibrac, and those who, like him, in the last century declaimed against the
abuse of sutures, were wrong in proscribing that of the ear. If it be true
that in wounds of the pavilion of this organ, adhesive strips, position, and a
bandage sometimes suffice to produce a good cicatrization, it is also true that
these means often fail, and are altogether inferior to the suture. When it is
performed, in whatever manner, I see no reason for including only the skin
and placing as many stitches behind as before, in order to avoid the cartilage,
according to directions given by the ancients. Leschevin, and quite recently
M. H. Larrey, have siiown that there is no inconvenience in including the
whole thickness of the ear in the loop of the stitch. Every w^ound by a cut-
ting instrument which completely divides the external ear, should be imme-
diately closed by the suture. Old divisions are to be treated in the same way
after making a fresh wound of their edges, conforming in other respects to
the principles laid down under the article Hare-lip. However slender may
be the pedicle of the flap, the division of it should never be completed before
attempting to restore it to its place and procure its coaptation by the suture.
If it mortify we are but where we were, and may remove it and leave the
wound to heal by the second intention. The facts observed at Heidelberg,
by M. Hoftaker, show, moreover, that we should not lose all hope of seeing
on the ear as on the nose, the adoption of a flap which had been completely
separated from the living tissues by the wound.
§ 2. Otoplasm,
The art of patching the ear is as ancient as that of replacing the nose.
Galen, Paulus Egineta, and Celsus, mention both. There is every reason to
believe that the Brancas, and several other surgeons of Italy, caused it to make
new progress in the course of the fifteenth and sixteenth century. In the
case he relates, Tagliacozzi says, that after the cure the resemblance between
456 NEW ELEMENTS OF
the two ears was so exact, that they might easily be mistaken for each other.
Since then, however, there has not been much notice taken of otoplasm ; so
that M. Dieft'enbach, of Berlin, who performed it with success, may in some
measure be considered as its inventor. Doubtless if the whole external ear
was removed, we could not think of reconstructing it, but would decide on
replacing it by a metallic one ; but when it is only partially destroyed, and
at least one half yet remains, we may attempt to restore it to its natural
dimensions. The lobe especially is very easily reproduced. When the loss
of substance does not extend beyond the ante-helix, or even when it comprises
nearly the whole of the helix, we should not despair of success. Without
even acquiring the firmness of the destroyed cartilage, the new tissues which
are put in its place become sufficiently firm to render the deformity much less
siiocking. As in the case of the nose, the skin of the neighboring parts is to
supply materials for the repairs. We begin by excising, smoothing, making
raw, the affected edge of the ear. We then incise above, below, or at the
posterior part of the concha, the integuments covering the temple, the mastoid
process, or the subauricular depression of the neck, a little nearer the meatus
auditorius than the level of the raw border, and in a direction parallel to this
border. Another incision, of more or less length, carried from each extremity
of the first, gives a flap of the form and extent desired, which is to be at least
one half larger than the loss of substance seems to indicate. In dissecting this
flap from the first wound towards its adherent edge, it is necessary to raise
with it a considerable thickness of cellular tissue, which lines its posterior
face and affords it nutrition and life. The surgeon then fits its free edge
to the bleeding wound of the external ear, and effects its union by means
of fine short needles, and a sufficient number of points of the twisted suture
delicately adjusted. To conclude, he has but to pass behind the kind
of bridge which results from this arrangement a bandage of linen spread
with cerate, for the purpose of preventing readhesion of the dissected skin.
After enveloping the whole with compresses steeped in a tepid infusion of mal-
lows, the patient is put to bed. At the end of three, foiir, or five days, if union
is well advanced, the needles may be removed ; at least those near the most
solid points. In a contrary case, it is to be seen if it would not be useful to
replace some of the first needles with others. When the cicatrix is firm, that
is, from the fifteenth to the thirtieth day, the tegumentary flap is to be sepa-
rated from the cranium, which, becoming free, requires new attention. First,
its inequalities are to be removed by rounding its angles; in a word, its ex-
ternal edge is to be shaped. For fear of its mortifying, it is to be dressed for
some days with emollient dressing, when it is treated, together with the wound
left on the head, as any other solution of continuity. In retracting it becomes
thicker, hardens, takes the form of a cushion, reddens after being at first pale,
and remains a longtime more highly colored than the nei!.';]iboring parts of the
external ear. Such at least was the state of things in the case related by M.
Dieffenbach.
§ 3. Perforation and Dilatation of the Auditory Canal.
Wlien imperforation of the canal of the ear is complete, and when it has its
source in the temporal bone itself, as of which I have observed a double ex-
ample on the body of a child four years old ; and a second, on one side only,
OPERATIVE SURGERY. 457
in another child ten or twelve years old, it is incurable and requires no kind
of treatment. On the contrary, to whatever degree the contraction maybe
carried, if there is barely room to admit the passage of a needle, as seen by
Lametrie, or if the coarctation is trifling and the obstruction occupies but a
point in length, or has invaded the whole extent of the canal, an attempt
should be made to remedy it by dilatation. Caustics were preferred by some
ancient authors, and Hippocrates himself might here become dangerous, and
would very rarely attain the end proposed. Canulae, sounds, or tents in-
creasing gradually in size, should be continued for a long time after the cure,
and even sometimes during life, for the wall of the canal preserves almost
always a great tendency to recover its former dimensions. In certain cases
the walls of the auditory passage are directly applied to each other, and cannot
be efficaciously separated but by a metal canula of a diameter equal to that of
the auditory canal in its normal state. If deafness depend evidently upon an
anomaly in the curvature of the cartilaginous prolongation of the ear, it may
be remedied by a permanent gold canula placed in this canal, of which M.
Boyer gives an example taken from his own practice. More frequently the
external ear is closed by a membrane or kind of diaphragm. If it be not too
far from the pavilion, it should be incised crucially with a bistoury wrapped
with linen to within two lines of its point. Its flaps are then cut away with
the same instrument, or small scissors, each being held by a hook. Others
have advised perforation with a trocar, and absorption to be determined by a
dilating body ; but this method is not so good as the first. The incision which
Paulus Egineta adopts when the accidental diaphragm is deeply seated, as in
the preceding case, is rejected by Fabricius ab Aquapendente, under the pre-
text that it exposes the internal ear to be penetrated, is practised at the pre-
sent by the greatest practitioners in all cases, except where it seems likely to
touch the membrane of the tympanum. In this case they follow the precepts
of J. Fabricius, having recourse to caustics, the best of which without doubt
is the lapis infernalis. Leschevin directs it to be fixed in the barrel of a quill,
and carried to the bottom of the canal through a silver canula. Three or four
cauterizations, with two or three days' interval between each, generally suffice,
and the operation, which gives hardly any pain, is not in the least degree dan-
gerous. In the same manner every other atresia, complete or incomplete, is
to be attacked, when it depends upon a fault of conformation of the soft parts,
and is not purely membranous. When the instrument has passed beyond the
obstacle, which is indicated by the sudden want of resistance, the trocar only
is withdrawn so that its canula may be used to conduct a bougie to the bottom
of the auditory canal, which is renewed every day with gradually increasing
size.
§ 4. Foreign Bodies,
A thousand different kinds of foreign bodies may be engaged in the auditory
canal, and a thousand different means have been proposed for their extraction.
In obliging the patient to hop on one foot, and making him use sternutatories,
Archigenes had the same intention as Celsus, who recommended the head to
be rested on a table and violently jarred by raising the patient by the feet, or
by striking the sound ear, or letting fall suddenly after lifting it the body on
58
458 NEW ELEMENTS OF
which it rests. Alexander, of Tralles, has given the idea of drawing them out
with a tube ; and Mesne, who reproduced it, has, like J. Arculanus, con-
structed for this purpose another instrument designed solely to pump out
liquids. The sucking pump, an instrument recently invented by M. Deleau,
which may be used for drawing out air, serosity, pus, &:c., as well as for in-
jections into the ear, is made upon the same principle. Leschevin, who con-
tends that air entering the canal of the pavilion is the ordinary cause of the
buzzing and tingling in the ears, had been anticipated by Reusner, who to
remedy this inconvenience proposed a small silver cahula to be left perma-
nently in the auditory canal. The hardened cerumen dissolves very well in
the oil of sweet almonds, as remarked by Avicenna, but still better in warm
soap-suds, or even pure water, if we trust to the experiments of Haygarth, who
rejects the oils as less advantageous. A solution of sea-salt dilutes it equally
well, according to J. E. Trempel. Consequently when deafness is produced,
as is often the case with persons of a certain age by the accumulation of this
substance, one of these liquids is to be introduced daily into the ear by a sy-
ringe or by cotton soaked with it, and when softened or detached the mass is
to be removed by a curette. If fleas, earwigs, or other insects, which some-
times insinuate themselves into the bottom of the auditory canal, are not caught
in the cotton and pitch, already prescribed by Hippocrates, or the pencil of
lint covered with turpentine which is presented to them for the purpose of
entangling tliem, we may attempt, like Hameck, to kill them by pouring in
upon them oil of bitter almonds, or, like Rhazes, a decoction of peach leaves.
A decoction of the sedum palustre, used by Acrel, produces the same effect.
But it is unnecessary at the present day to combat Verduc, who maintains
that the rennet apple has the property of extracting them ; or Leschevin, who
boasts that a small piece of potatoe is a special antidote against the earwig.
It is proper at first to attempt their extraction, whether living or dead, with
tlie forceps.
As to foreign bodies of a considerable volume, which Paulus Egineta has
correctly ranged in two distinct classes, the first, those which absorb humidity
and may become swelled in the parts, and the second those which are imper-
meable, they deserve all the attention of the surgeon. Violent inflammation,
abscess, caries of the bone, cerebral symptoms, and severe pains of the head,
may be caused by their presence. On opening the body of a patient who had
died in this manner, Sabatier found the petrous portion of the bone perforated,
the dura mater inflamed, an abscess, and a ball of paper in the substance of
the bone itself. In the case of a girl, who had been long subject to convulsive
tits and nervous symptoms of every description, F.de Hilden obtained a com-
plete cure by extracting from the ear a foreign substance, which had been
introduced into it seven years before. An analogous observation is related
in 1829, and scientific compilations are crowded with similar examples. M.
Larrey, however, remarks, that in a soldier whom he attended, the foreign
body remained in place for ten years without producing any unpleasant symp-
tom. It should not be forgotten that these several substances, which are
sometimes a bean, a pea, a cherry-stone, a shot, a piece of glass or corn, a
pebble, &.c., sometimes come out of themselves after the first symptoms pass
off, and after producing suppuration more or less profuse. It is important to
r?,raember, especially in practice, that the patients and their relatives often
• OPERATIVE SURGERY. 459
insist strongly that the ear contains a foreign body, when in fact it is com-
pletely clear. A terrified mother brought her child, of about five years of age,
to one of the public consultations in the capitol, to have a cherry-stone re-
moved which had been twenty-four hours in the ear. Attempts of every kind,
uselessly renewed every morning for three days, caused excessive pain, inflam-
mation, and fever; and when, not daring to do anything furtlier, the surgeons
thought to ascertain whether if the organ of the little patient really contained
a cherry stone, they found nothing of it. Such instances of inattention have
often given rise to the most serious consequences. M. Boyer gives two ex-
amples, and there are few surgeons who have not had occasion to observe
similar cases.
If inclining the ear be insufficient to extract the foreign body, we must en-
deavor to reach it with forceps when its form is long and flattened. A small
hook is sometimes best for extracting those which are somewhat soft. To
such as these relates the advice of dividing them, and reducing them to small
pieces with a long and narrow blade of wood so as to remove them piecemeal.
Brittle bodies require much more precaution. A false pearl, says M. Boyer,
being broken in the auditory canal by a surgeon in attempting to extract it,
put the life of the patient in danger, and actually produced suppuration of
the tympanum and loss of hearing. In such a case a small but solid curette
should be used to look for it, following the inferior wall of the canal so as to
conduct it beneath the body to be removed, to be then used as a lever of the
first kind by depressing the handle at the moment of extraction. A cherry-
stone, which had resisted these manosuvers, at length terminated in the ear,
so that if \ye are to credit M. Donatus, it was extracted by the sprout ; but I
need not expose the improbability of such a fact. The process of F. de Hilden,
adopted by C. de Solingen, has been justly put aside; it consists in carrying
first a canula upon the foreign body, and then through this a second one
designed to fix it by means of teeth at its extremity, while a kind of gimlet
is inserted, and the whole withdrawn together. What cannot be done with
the curette, will not be attained by this apparatus, which is better adapted for
pushing the body into the cavity of the tympanum than for extracting it. In
difficult cases, Paulus made a crescentic incision behind the concha, in order to
penetrate to the bottom of the canal, opening the cartilage from without in-
wards, so as to be able to push the foreign body from within outwards with an
appropriate instrument. This operation, which was also proposed by Dionis
and Verduc, is now totally abandoned. Perhaps, however, it should not be
rejected entirely, when danger presses and all other means have been fruitless.
For the rest, whether this or that instrument be used, it is always proper, be-
fore commencing the operation, to drop a little oil into the ear to lubricate the
parts and render them less irritable. Afterwards nothing more is necessary
than emollient injections for some days, at least whenever the manoeuvres
employed excite no fear for the future development of formidable symptoms.
Otherwise, antiphlogistic, hypnotic, and soothing medicines become indis-
pensable.
§5. Polypi.
The several kinds of treatment to which polypi of the nasal fossae have
been subjected, have also been presented for those of the ear. Aranzi con-
460 NEW ELEMENTS OF ,
tends that they are to be cured with caustics, especially with an ointment of
red precipitate. De Vigo employed against them by turns, hot iron, caustics,
the liguture, and tlie forceps. Paul removed them with a bistoury made
expressly for the purpose, or rather with his pterygotome. G. de Salicet
cauterized the root after tying them with a horse-hair or silken thread. At
the present day the ligature and extraction are almost the only methods used.
The ligature, which F. de Hilden, and after him Marchetti and Purmann
applied by means of a silver plate bent to the form of a forceps, is rendered
easier of application, says C. de Solingen, by piercing the base of the tumor
as a preliminary with a thread in the manner of a hook. It is really ap-
plicable but in a small number of cases, when the polypus is redunculous and
narrow, and near the external opening. It is performed with a hempen thread,
and the canula of Desault, or rather after the process of F. de Hilden, modified
by Solingen, or again by carrying with forceps a slip-knot or noose of thread,
making it glide over a stylet to the root of the polypus. When the thread is
placed in any manner whatever, its two ends are passed through a serre-noeud,
and after this there is nothing particular in the operation. Excision is prac-
ticable under the same circumstances, and in almost every case in which tlie
ligature can be tried. The polypus bei*ng engaged on a hook, it is drawn
forM'ard, turning it back a little to expose its root, which is divided with a
single stroke of the bistoury. As to extraction, the only method, in my
opinion, which can be usefully applied to polypi whose root is deeply seated,
and which may also be considered applicable to the others, is effected with
ordinary forceps with pierced blades, being concave, thin, and furnished with
teeth.
The speculum auris of G. Fabricius, and that of Cleland, as well as all that
have been proposed before or since, are unnecessary if not prejudicial. The
forceps supersedes them. The surgeon opens them moderately, and engages
them between the tumor and the parietes of the canal, which he gently sepa-
rates, thus entering them as deeply as possible, and after securing a grasp of
the polypus, turns them upon their axis and extracts the whole, half drawing,
half twisting them. The blood which immediately escapes conceals the parts
in such a way, that most frequently the exploration necessary to render it
certain if any thing more exists or not in the auditory canal, has to be
deferred until the next day. This hemorrhage is never dangerous. A tent
of charpie smeared with cerate, or a dossil of lint, to prevent the bleeding
surfaces from being irritated by contact witli the air, form all the dressing
required, and that which is always employed after extraction of polypus of the
ear. In case some heterogeneous tissue remains after th« operation, before it
increases we should attempt to destroy it either with hot iron, as prescribed
by G. de Salicet, F. de Hilden, &c., or with caustics, which are generally
preferred at present. The canula of J. de Vigo, open on the side, permits, it
is true, the fire to be carried on the diseased point ; but as we have sometimes
to act upon large surfaces, or very near the membrane of the tympanum, actual
cautery in this place is not without danger. Nothing is more simple, on the
contrary, than to reach tlie polypus through the same canula, with a pencil
charged with butter of antimony, the nitrate of mercury, or any other caustic,
supposing even that the lapis infernalis might not take the place of these
several means. Polypi of the ear are developed so slowly, and produce so
OPERATIVE SURGERY. 461
little derangement of function, that many patients carry them for years before
requiring the assistance of art. At this very moment (February, 1830) I have
just extracted one at the liospital St. Antoine, from an adult who had carried
it for fourteen years. Extraction in this case is not without danger. The
tympanum, deprived for a considerable time of tlie action of its natural stimu-
lants, becomes irritated by their presence, if suddenly restored without
precaution. It is the same as with an eye just operated on for cataract;
it must at first be kept in darkness ; and exposed to the light but by insensible
degrees.
Art. ^. — Internal Ear.
§ 1. Perforation of the Membrane of the Tympanum.
Plemp is the first, I believe, who maintained that the hearing might be
preserved although the membrane of the tympanum were perforated. The
fact which he adduces in support of his assertion, appeared at the time so
extraordinary, that Verduc refused to give it credence ; and Valsalva, who
mentions experiments tried upon animals, also rejected its possibility, notwith-
standing the authority of Riolan, supported by the case of a deaf and dumb
person, who having plunged an ear- pick through the membrane of the tym-
panum, was suddenly restored to hearing. But J. Munnicks, and more par-
ticularly Cheselden, having again brought it forward, sustaining it by new
observations, it must be received as a demonstrated truth. Cheselden did
more ; since, says he, the loss of the membrana tympani does not bring on
deafness, one might perhaps, by perforating it when thickened or degenerated,
in some cases restore the faculty of hearing. Unfortunately the criminal in
whom he made the application of this idea, was deaf from another cause, and
his operation was without success. Although taught again of late by M. Por-
tal, and formally proposed by Busson, as a means of evacuating abscess of the
tympanum, perforation of the membrane could only be revived effectually
by Sir A. Cooper, who first practised it with success in 1800 and 1802.
Attempted since with various results by a number of surgeons, it has yet
to take rank among the useful and regular operations of the healing art. A
small trocar slightly curved is the only instrument used by Sir A. Cooper,
who, to avoid the malleus and the chorda tympani, correctly advises the mem-
brane to be pierced in its anterior and inferior fourth. Himly, who pretends
to have publicly described this perforation in the year iZOr, says that the
opening made with the trocar soon closes, and to prevent this, it should be per-
formed with a hollow punch, which M. Fabrizi, of Modena, intending io
modify, has singularly complicated. According to this remark, the cataract
needle, preferred by Arneman ; the little square knife like Key's needle, with
which Buchanan thought to divide the fibres transversely and favor the retrac-
tion of the lips of the wound ; the triangular sound of Paroisse, and the kysti-
tome cache of Fusch, should all be proscribed ; as also the little punch with
ciroidar shoulder to prevent its passing too deeply, invented by Rust; a knitting
needle, which according to Michaelis might also be adopted; the simple st3^1et
of M. Itard ; the needle which M. Saissy encloses in a small tube of gum-
elastic ; and the kystitome of la Faye, which seems at least to me more con-
462 NEW ELEMENTS OF *■
venient than any other instrument. For the purpose of securing a permanent
opening, M. Richerand thought it would be better to perforate the membrane
of the tympanum, by cauterizing it with a pencil of lapis infernalis, and Zang
suggested the idea of leaving a piece of catgut in the wound. To tiie three
successful cases of Sir A. Cooper, may now be added a great number of others.
That of Saunders, for instance, who cured by this operation a deafness of three
years' standing ; another, of Paroisse, in a patient who had been deaf for eight
years ; those of Michaelis, Rust, Itard, Saissy, Maunoir ; and those of Henrald,
who declares that he succeeded twice in three attempts ; but it must not be
dissembled, that the most of these practitioners, Celliez and M. Itard, among
others, and M. Dubois, at four different attempts, have also performed it with-
out deriving the least advantage from it. Trury and Kauerzhave not, I believe,
been more fortunate, and besides, it is only proper in very few circumstances.
It would be wrong to expect any thing from it, for example, when the deafness
is caused by a lesion of the labyrinth or of the middle ear, the nerves, the
small bones, or their muscles ; in a word, whenever the disease does not arise
from pure and simple obliteration of the Eustachian tube. Its design, in fact,
is to allow an entrance into the cavity of the tympanum and the mastoid cells,
and no other indication can be fulfilled by it. Pus, serosity, mucus, and other
liquid matters, the discharge of which it might favor, would find a more natu-
ral route by the pharynx, if the trumpet were not closed ; and the perforation
of the tympanum should be rejected as long as it is not indispensable, or when
it is possible to penetrate to the middle ear by any other way. This is not
because it is dangerous, or that it may occasion very serious accidents. As it
is scarcely painful and rarely followed by general reaction, nothing forbids its
being tried when nothing further is to be expected from other means ; but we
must not promise ourselves too brilliant results from it, or found upon it too
sanguine hopes. Simple puncture is of no value ; the opening is often closed
in a day. Excision itself does not place it beyond risk of this ill result, for
the lack of a proper instrument. The hollow punch of M. Deleau, a kind of
sheathed spring which expands at the will of the operator, and which suddenly
pushes against each other two small cutting circles so as to detach neatly a
disk of the tympanum^ although one of the most perfect, is far from being
always successful.
§ 2. Perforation of the Mastoid Cells,
When in consequence of violent or even chronic inflammation, lively, dull, or
tensive pains are experienced in the ear; when there are strong reasons to
believe that an abscess is formed in this part, or that injections into the cavity
of the tympanum would be advantageous, or that caries exist, or some splin-
ters of bone which should be removed, perforation of the mastoid apophysis
seems to be clearly indicated. The passage in which Galen says, that if ulcers
of the auditory canal have affected any of the hard parts, it is necessary
to mak-e an incision behind the ear, to scrape the bone, or remove the exfolia-
tions, is all that appears to relate to this subject in the ancient authors. But
Valsalva has already made the remark, that injections through the mastoid
cells return by the mouth. Riolan and Rolfinck expressly assert it. Heuer-
ifiann, who saw an abscess of tlie ear point at the mastoid apophysis, and there
, OPERATIVE SURGERY. 463
leave a fistula, concludes from it, that it would be best in such a case to apply
the crown of a trepan behind the concha, without giving time to the pus to
affect too deeply the spongy tissue of the apophysis. A patient was advised
by J. L. Petit, but could not be induced to submit to this operation, while by
this means the same author has saved a number of others who were at least as
seriously affected. Observations of the same kind have been published by
Morand, Martin, &c. It was chiefly on these that Jasser relied in operating on
the soldier, in whom he opened the mastoid process of one side containing an
abscess with caries, and that of the opposite side for simple deafness. Fiedlitz
performed it with success on both sides, for a woman whom a quartan fever
had deprived of hearing. This author, quoted by Richter, relates two other
cases not less remarkable, Loefier, who boasts of it, recommends the use of a
perforating trepan, furnished with a ledge to prevent its penetrating too far, and
that the soft parts be incised twenty-four hours before perforating the bone, so
as not to have an effusion of the blood into the mastoid cells ; and lastly, that
there be daily injections through the opening, which is to be kept dilated with
a leaden sound. Hagstroem, who however has nothing to boast of from it, enters
into more minute details on the mode of performing it than Loeffler, whose ideas
he principally adopts. If a fistula exist, says he, we must confine ourselves to
dilating it. Otherwise the bone is to be denuded, avoiding the auricular artery,
which is usually very near the concha, after which it only remains to open the
apophysis from behind forwards, with a gimlet, a punch, or trocar, rather than
with a trepan. Acrel thinks it useless when the bones are sound ; and Murray has
well remarked that before puberty the mastoid cells, being scarcely developed,
it would in reality be to no purpose. The case of Doctor Berger, who died after
being operated upon by Callisenand Koelpin, and in whose cranium no mastoid
cells were found, proves that they may also be wanting in adults. Similar facts
related by Morgagni, did not deter Prost or Arnemann, who declare they have
resorted to it several times with success. Dropsy of the cavity of the tym-
panum and simple abscess, do not absolutely require it. They are evacuated
as easily by perforating the membrane of the tympanum, which is a far less
painful and less serious operation. After all it is only in phlegmasias, which
are accompanied with necrosis or caries, and are inclined to point behind the
ear, that we are in any way obliged to have recourse to it,
Manual,-^A crucial or T incision, lays bare the whole external face of the
mastoid apophysis. After the bone has been scraped, there is applied to
it either a perforator, the small crown of a trepan, a gimlet, or a trocar. Care
is to be taken to incline the instrument a little forwards and upwards
as it penetrates. When it has reached the auditory cells, it is to be withdrawn
to permit the operator to enlarge the opening immediately if necessary. Injec-
tions are tlien to be cautiously thrown in. Tents, dossils of lint, or a sound
of lead, should be daily placed in the perforation until the cavity of the tym-
panum have returned to its natural state. The scissors, or the gouge and
mallet, used by J. L. Petit are to be preferred if the bone is widely necrosed,
and if it is necessary to separate large fragments. If nothing indicate before-
hand where the instrument is to be applied, it is from six to eight lines above
the summit of the apophysis. The largest cells correspond to this point.
The auricular artery, which is found in front, and the sub-mastoid, which is
below, may be easily avoided.
464 NEW ELEMENTS OF ♦
§ 3. Cathcterism of the Eustachian Tube,
The idea of penetrating into the cavity of the tympanum through the
pharynx is already very ancient. Archigenes, Vasalva, Munnicks, and Busson,
without doubt had it in mind, when they advised the vapor of water, tobacco,
&c., to be inhaled, and the nose and the mouth to be tightly closed to force
them towards the ear during expiration. In 1724, Guyot, postmaster at
Versailles, and Cleland, in 1741, invented each an instrument for injecting the
tubes, one by the mouth, the other through the nose. The slightly curved
sound of J. L. Petit, rendered the operation still more easy. Douglas and
Wathen decided in favor of the process of Cleland. Heuermann and Ten
Haaf, adopting that of Guyot, introduced a female catheter into the tube
through the mouth, above the velum palati, and then screwed a small syringe
to the other extremity of the tube. It is further recommended by Falken-
berg, Sims, Chopart, and Desault; by Callisen, who performed it sometimes
through the nose and sometimes through the mouth, and describes very well
its mechanism ; by Buchanan, Itard, Boyer, Richerand, &c. Proscribed as
inapplicable to the living subject by B. Bell, and as dangerous by Trempel,
these injections have been brought into vogue again and highly recommended
by M. Deleau, who appears to have effectually obtained from them the happiest
results. As a mechanical means they remove obstructions of the tube; as
medicinal, they act with efficacy upon inflammations, engorgements of all
kinds, thickened matters, and fluid collections in the cavity or guttural canal
of the tympanum. It is therefore perceived of v/hat benefit they may be in
deafness, which depends on any of these causes.
No doubt we may, and that very easily, penetrate the tube by carrying a
bent sound through the mouth above, behind, and on one side of the velum
palati, as it was done by Heuermann ; but the operation being still more easy,
and especially more certain through the nasal fossse, this is the way generally
followed at the present day. The instrument of Saissy, Itard's sound, shaped
like an Italic S cr rather an algalie, which differs from a female catheter only
in being open at both extremities without any holes on its sides, and a small
syringe to force up liquids are all that it is necessary to procure in this case.
A gum-elastic sound, supplied with its stylet and suitably curved; a buttoned
stylet, in case the obstacles are removed by a solid body, may, strictly speak-
ing, take place of other catheters. The surgeon, placed on the side and in
front of the patient, bends back the head with one hand, takes in the other the
sound smeared with some unctuous substance, presents its beak to the orifice
of the nose, and causes it to glide over the floor of the nasal fossse through the
inferior meatus, taking care to keep its convexity towards the septum, and a
little inclined upwards. Arrived at the superior face of the velum, he raises
a little the extremity of the instrument without letting it quit the external
wall of the nostril, which carries it insensibly upon the superior part of the
maxillary meatus ; he continues it in this direction, and infallibly enters it into
the mouth of the tube, which from thence looks obliquely outwards, back-
wards, and upwards. As soon as the sound is sufliciently engaged, the syringe
is fitted on as for injecting a hydrocele, and every body knows what then
remains to be done. The operation is renewed once or twice a day, and, as
OPERATIVE SURGERY. 465
it is plainly seen, nothing prevents the entrance of any medicated fluid that
may be deemed necessary into the middle ear. If the injection be arrested
in the tube, and from some cause cannot be made to advance, it will be a
case for removing the syringe and passing up the stylet as far as the obstacle,
so as to remove or destroy it. But in this place force is not to be used but
with great caution ; and before having recourse to it, we should be well assured
that it is indispensable — that the best directed manoeuvre cannot supersede
it. M. Deleau, who obtained the happiest results from this kind of medi-
cation, finding that the beak of the metallic sound would not fail of soon
striking against the parietes of the tube when an attempt is made to advance
it some lines, that its inflexibility creates pain, and that aqueous injections
penetrate thus with great difficulty into the auricular cavity, thought to sub-
stitute for it a flexible sound and to force in atmospheric air. Y/ith the pro-
cesses of this surgeon' the operation is possible at every age. He even
succeeded in passing his sound by the nostril opposite the diseased ear ; which
is an extremely happy thing when any alteration or deviation prevents its
being carried through«the corresponding nostril. I have seen two boys, one
four, the other seven years old, submit with a very good grace to the
manoeuvres of his method, and without giving the least sign of pain. By means
of a silver stylet from four to six inches long, with a strong curve near one
extremity, carrying a ring at the other, the diameter of wliich varies from a
line to a line and a half, he conducts a gum-elastic sound to the tube. The
patient seated on a chair leans his head a little backward, supporting it on
the back of his seat or against a cushion made for the purpose, and supported
by a staff which may be lowered or raised at pleasure. The operator takes
his instrument, previously oiled ; presents it to the nostril, holding it like a
pen in his right hand, with its concavity turned downwards and outwards;
enters it, rapidly following the floor of this cavity soon touches tlie palatine
vault (vvhicii is known by an involuntary movement of deglutition, and by
the instrument's having arrived at the depth of two or two and a half inches);
raises its beak outwards and upw^ards by a circular or rotatory motion to bring
it into the tube ; then seizes above, with the thumb and index finger of the
left hand, the free extremity of the catheter, if it is engaged within the tube ;
attempts to make it advance while the stylet is kept immovable by the right
hand ; moves it tims as far as the obstacle, which it removes as a coarctation
of the urethra is removed, and withdraws the conducting stylet when he
thinks he has entered sufficiently far ; screws a silver pavilion to the external
orifice of the canula, which he retains in place with a wire twisted in the
shape of forceps, which embraces at the same time the corresponding ala of
the nose ; fits to this pavilion the beak of a syringe, a bottle, or bellows of gum-
elastic; uses it to force the air beyond the obstacle, not exceeding a degree of
pressure which habit alone teaches to proportion; discovers by the noise
which is heard in applying the ear to that of the patient whether the cavity is
sound or diseased, empty or full, whether the gas which is forced in can or
cannot return between the sound and the parietes of the tube ; substitutes the
tunnel of a reservoir furnished with a manometer, in which there is a pump
to compress the air ; turns the stopcock of this apparatus, and establishes a
double atmospheric current in the ear, one entering by the sound, the other
59
466
NEW ELEMENTS OF
issuing between it and the guttural canal, augmenting or diminishing the force
of this injection, and stops in the course of one or several minutes.
JRemarks. — In penetrating through the opposite nostril the instrument is a
little more curved, and its beak is slightly bent again in the direction of its
main convexity. Held in the same hand, its concavity turned downwards and
inwards, it is made to pass along the inferior margin of the septum. When at
the velum palati, the hand is elevated by carrying it outwards, to incline its
extremity behind the vomar and reach the tube; the rest is performed ac-
cording to the directions already laid down. In the one case as in the other,
if the sound is not well placed, the patient himself makes it known after he has
once undergone the operation. Its direction and position otherwise sufficiently
announce it to the surgeon. For positive assurance, however, there is an easy
means. The stylet being withdrawn, air or a liquid is to be thrown through
thecanula; the injection will fall into the pharynx if the position is wrong,
and in the contrary case will either not pass or will enter th€ cavity of the
tympanum. M. Deleau is of opinion, that by passing the sound briskly though
gently forwards, there will be less hindrance and fatigue than by the common
method. Experience has demonstrated to him that there is less inconvenience
in beginning again once or oftener, and turning the beak rapidly towards the
tube, than in feeling slowly about it to find its entrance. His flexible canula
has a very great advantage. Pushed forwards by the fingers of the left hand
while the stylet is held without, it enters and adapts itself to the direction and
bendings of the canal to be traversed. From the pressure it meets with in
advancing, we perceive at what distance the contraction exists ; what is its
degree, and even its density. If the first instrument used appear too large, it
is replaced by a smaller, and vice versa. The curvature of the inflexible
sound allows nothing of this ; with it the injection is thrown more or less
obliquely against one of the walls of the canal ; the other directs it, on the
contrary, in the axis of the tube. If after the removal of the obstacle the air
makes a hissing noise in the cavity of the tympanum upon the membrane, or
a dry sound, the conclusion is that the middle ear is not aftVcted ; if it seem
rather to agitate a liquid, if it is mucous, we are authorized to infer that there
exists pus, blood, serosity, or at least an engorgement of the internal mem-
brane of the middle ear. In both cases, if the tube is evidently obstructed or
contracted, and the patient has better perception of sounds immediately after
than before the catheterism, the deafness depends on the condition of the tube,
and there is every reason to believe that it may be removed. When no change
results, the evil probably lies elsewhere ; and we may be pretty certain that in
the end there will be no advantage derived from this operation. Sharp pain
produced by the injection announces an acute phlegmasia, or too great nervous
irritability, which is to be overcome by the usual treatment. In simple ob-
struction or purely chronic phlegmasiae, there is scarcely any pain during the
operation. M. Deleau explains the action of the air in a manner altogether
mechanical ; it sweeps out, blows, and cleanses by degrees the cavity of the
tympanum and the mastoid cells. In returning between the sound and the
tube it necessarily makes an effort, and becomes a dilating and resolving body
by the compression it exercises on the engorged tissues. Water and other
liquids produce no other medical effects than gases, and are much more apt
«
OPERATIVE SURGERY. 467
to wound and rupture the membrane of the tympanum. Every professional
man will, however, understand that each case may require special modifications,
and that it is the same as far as relates to the operative process in contractions
of the Eustachian tube, as in coarctations of the urethra; and that on this point
dexterity and frequent practice, joined with great prudence, will alone give
sufficient skill to him who wishes to reap any fruit from catheterism of the
guttural auditory canal. It would consequently be vain to expect to attain
the knowledge and tact possessed by M. Deleau, without long practice. Thus
does it become a very simple matter how this practitioner has succeeded in
affording relief or cures to a host of deaf and dumb, who had fruitlessly sought
elsewhere the amelioration procured in his establishment.
It remains for me to offer a suggestion. As engorgement, thickening, or a
phlegmasiac condition of the mucous lining of the tube is admitted as a cause
of deafness, might it not be allowed to try against this affection what is em-
ployed with so much advantage in the radical cure of it in the urethra, viz.,
the nitrate of silver ? Having no authority in support of this suggestion, I
merely throw it out in passing, without forgetting the fear naturally inspired
by the introduction of caustics through the pharynx into the ear.
TITLE n.— OPERATIONS ON THE TRUNK.
CHAPTER I.
Nech.
SECTION I.
Lateral and Superior Regions.
Art. 1. — Parotid Gland,
To take literally what has been said by the authors of the last century,
nothing should be so simple as the total eradication of the parotid gland. In
our days, on the contrary, nothing seems more difficult ; so that many great
masters, M. Boyer among the rest, deny even its possibility. It is true that
the greater part of reported cases are far from being conclusive. Thus, as
Richter has already remarked, and Burns demonstrated, the assertions of
Heister, who is said to have extirpated the parotid several times ; those of
Scultetus, Yerdier, Palfyn, Van Swieten, Gooch, Berh, Roonhuysen, Gotte-
fried, Errhart, &c.; of Garengeot, who maintains that the operation never
causes hemorrhage ; of Kaltschmidt, who avers that he performed it a number
of times with success, among others for a tumor which weighed three pounds ;
of Acrel, who arrested the hemorrhage by simple tamponnement ; of Bur-
graw, of Hezel, of Alix, who removed a mass ^ weighing four pounds from
468 NEW ELEMENTS OF
beneath the ear without producing the least effusion of blood ; of Kauw,
Boerrhaave, and some others ; evidently relate to the removal of lymphatic
tumors developed in the depth of the parotid space, and not to the parotid
itself. Mightnotthe same be said of the following observations? In 1781, J. B.
Siebold thought that he had entirely removed the parotid, because after the
operation it was easy to discern the digastric and stylo-hyoid muscles, as well
as the carotid artery. In the case of a student, mentioned by Heister, it was
necessary to go so deep that the carotid gave rise to a fatal hemorrhage.
Thinking to remove a wen, Soucrampe perceived that he was extirpating the
parotid and continued his operation, dissecting out the gland with a bistoury.
** I guided the instrument," says he, *' with the index finger of the left hand,
to distinguish the pulsation of the arteries and especially of the carotid."
Less blood was lost than the surgeon expected, and the patient was perfectly
restored. In 1796, Ch. G. Siebold, who removed an enormous tumor from
the side of a young lady's neck, says, that there resulted so deep an excava-
tion that all the assistants were obliged to admit that the parotid gland hatl
been extracted entire. In an operation by Klein, in 1820, the facial nerve
was cut. It was necessary to lay bare the carotid artery and the pneumo-
gastj'ic nerve, to turn aside the temporal, external maxillary, auricular, and
transversalis faciei arteries, and tie several of these vessels. At the end of
eigriteen days the cure was complete. In the case which occurred to M. Idrac,
of Toulouse, there was no artery to tie, but the wound presented the same
aspect as in the patient of the elder Siebold, and the diseased portion, as
large as the fist, was round and rugose ; inwards w^as a projection moulded in
the space bounded by the mastoid process, the auditory canal, and tlie margin
of the jaw. It was of the same nature throughout, and presented exactly the
form of the parotid. The patient was cured without the occurrence of pa-
ralysis. The observation of M. Lacoste difters from that of M. Idrac only in
having an abundant hemorrhage, twice renewed, and which placed the life of
the patient in danger. The tumor j-emoved by M. Prieger weighed nearly
three pounds. The external maxillary, temporal, and auricular arteries, but
not thfe carotid, were divided and tied. The woman survived. If we are to
believe Mr. Kirby, we may be assured that after his operation the interval of
the pterygoid muscles was empty, the auditory canal displayed as well as the
temporo -maxillary articulation and the whole length of the styloid process.
Nevertheless, plugging with sponges sufticed to arrest the hemorrhage ; and
notwithstanding an erysipelas of the face which supervened, the patient was
cured. As to the case related by M. Pamard, the author himself admits that
the parotid was not entirely extirpated. M. Nasgele maintains that tlie gland
may be removed from the dead subject without lesion of the facial nerve, and
declares that he has performed it successfully in his hospital without producing
paralysis. If in these various observations the authors are far from giving
all the details, and all the proofs capable of carrying their ow^n conviction to
the minds of their readers ; if in several instances the little they do say tends to
prove the contrary of what they have advanced, it is not, therefore, the less
probable that some among them refer really to the eradication of tlic principal
secretory organ of the saliva. Besides, there actually exist irrefragible proofs
of such an operation. Althougli M. Goodlad reports a case quite circum-
stantially, yet to Beclard is due its first demonstration. His patient, operated
OPERATIVE SURGERY. 469
upon in 1823, at the hospital La Pitie, had the muscles of the whole of one
side of the face paralysed, and, as he died some months after of chronic
meningitis, it was iii the power of the operator to prove on the dead body that
all the gland had been positively extirpated. A patient, who was operated
on by M. Gensoul, in September, 1824, and died in the courseof the year 1825,
if we admit without reserve the assertion of the author, proved also that the
removal of the parotid gland had been complete. With better fortune than
at first, M. Gensoul repeated the operation in 1826, and with full success,
but the patient remained with paralysis of one half of the face. M. Car-
michael met with the same good fortune some time previously, that is, in 1818,
and mentions the same peculiarity as M. Gensoul as the consequence of the
operation. In 1826, also, M. Lisfranc had occasion to remove the whole of
the parotid, and exhibited the patient and the morbid portion to the academy,
and proved satisfactorily after death, which happened after the lapse of some
weeks, that there was no portion of the gland remaining in the parotid space.
In the operation performed by M. Heyfelder, of Treves, in the month of
June, 1825, the patient lost but three or four ounces of blood, but a very
small lobe of the gland was left in front, and the paralysis of the face in the
end spontaneously disappeared. In the operation by Dr. G. M'Clellan, in 1826,
the success, says the author, was complete, although the gland was entirely
removed. That of M. Cordes, of Hirschetrg, who declares that he did not
leave the least particle of the gland, is equally established. M. Bernt pro-
fessed also to have performed it with success. The Archives contain another
example, in which layer by layer was removed down to the carotid. The
German journals of the last year report a new case of the successful removal
of the parotid. In the operation which M. A. Fonthein de Syke performed,
in November, 1828, on a woman twenty -three years old, the carotid was not
wounded, no hemorrhage took place, and the cure perfect on the thirtieth
day. The paralysis itself, which was apparent at first as in the preceding
cases, had completely ceased. The most recent case that I am acquainted
M'ith, is that of M. A. Magri, of Soreinese. In January, 1829, this surgeon,
assisted by M. Madonini, extirpated from the side of the neck a tumor which
included the whole of the parotid, without being obliged to tie the trunk of
the carotid. The patient, a countryman, thirty-six years old, was restored in
twenty-six days, with the exception of paralysis of the face, which remained.
M. Dugied, who gives an extract of the greater part of these facts, mentioned
also by Messrs. Hourman and Pillet in their dissertation, says that Messrs.
A. Cooper and Weinhold have extirpated several times the entire parotid.
But I have not been able to find where these observations have been published,
except those of M. Weinhold, who preserves one of the glands in his cabinet,
and exhibits it to any one who desires to see it.
Anatomical JRemarks. — This gland, which is enveloped in its aponeurosis,
and continuous in some measure with the sub -maxillary gland in passing over
the internal face of the angle of the jaw, separated from the skin by a layer
of adipo-cellular tissue of more or less density, is nearly of a pyramidal shape,
and is somewhat firmly connected to the auditory canal above, to the mastoid
process and sterno-mastoid muscle behind, and more or less prolonged in
front, upon ih^ external face of the masseter. On its anterior face, it con-
ceals or incloses between its lobes, as you go from above downwards and from
470 NEW ELEMENTS OF
without inwards, first, the arteria transversalis faciei, and the two principal
branches of the facial nerve at the point of their passage over the margin of
the jaw; secondly, parallel to this margin, the superficial temporal artery and
vein ; thirdly, the external carotid and the origin of the internal maxillary ;
and fourthly, the pterygoid muscles, and some branches of the pharyngeal
vessels. It rests below upon the stylo-maxillary ligament, the digastric and
stylo-hyoid muscles ; behind, between the ear and the mastoid process, upon
the auricula artery; lower down upon another quite large branch, which
crosses the mammoid protuberance; more deeply, upon the stylo-mastoid
artery, and mediately upon the occipital. By its summit it passes near
the internal jugular vein, the great hypo-glossal, the pneumogastric and
the great sympathetic nerves, between the transverse process of the first
vertebra and the pharynx. One of its branches is generally prolonged
between the two carotids ; another often advances between the stylo-glossus and
the stylo-pharyngeus muscles, the internal carotid artery, and the jugular vein :
the whole cover the styloid process, which they embrace, and the root of the
anatomical bouquet of Riolan. In fine, it is traversed obliquely from above
downwards, from within outwards, and from behind forwards, by the trunk of
the facial nerve, which ramifies in its substance, where is also found the
vein which forms the communication between the two jugulars, very small lym-
phatic ganglia, and other arterial and venous branches of much less importance.
Manual. — ^When the operation is determined upon, the first question that
presents is, whether it is necessary or not to imitate M. Goodlad, who pre-
viously tied the carotid artery? At the commencement, it is never known
whether the whole of the gland will have to be removed, or whether we may
be permitted to leave a part. If in the first case a wound of the external
carotid is almost inevitable, the internal carotid may very frequently be
respected. In the second, there is a probability of preserving both. By its
action on the encephalon, and the rest of the organization, this ligature is far
from being indifferent. Without admitting, with M.Tuson, that proximately
or remotely it is constantly fatal, it would at least be very wrong, whatever
may be said of it by some moderns, not to regard it as one of the most dangerous
operations in surgery. Here, besides, its execution would be extremely
difficult on account of the changes of relation between the parts, at least if the
external carotid only is to be tied. In keeping the thread around it only du-
ring the operation, as was done, or appears to have been done by Beclard^
Carmichael, Gensoul and Lisfranc, we have at least the chance of dispensing
with it, if it be possible, without being thereby exposed to meet more nu-
merous obstacles, than in any other manner.
1. Operation. — The instruments which may be required are a straight bis-
toury; a convex bistoury; a probe-pointed bistoury; straight and curved
scissors; a dissecting forceps; a steel director; a scalpel, of which the flat
handle may serve to separate the parts if occasion require ; needles armed
with ligatures, and all that may be necessary for placing a ligature on the
carotid artery. The rest of the apparatus consists of sponges, rolls of charpie»
dossils of lint, agaric, long and square compresses, one or two bandages, and
other things required in every great operation.
First Stage. — Resting on the sound side and supported by assistants, the
patient is to be placed so as to be able to breathe and spit freely. One person
OPERATIVE SURGERY. 471
t
should be ready to compress the trunk of the primitive carotid in case of
accident. The volume, the form of the tumor, and the state of the integu-
ments, determine the kind of incision which should be first preferred. If the
skin is sound, and free from adhesions ; if the body to be removed does not
exceed in size a hen's egg, the crucial or the T incision is the best : otherwise
recourse must be had to the elliptic incision, in order to remove with the
scirrhus a flap of the cutaneous cushion. In this latter case, if the extent of
the tumor require it, nothing prevents making on each lip of the ellipse after-
wards another incision, which will transform it into a T, and after the opera-
tion will reduce the whole to a crucial incision. Unless the disease extends
very far towards the mouth, it is less advantageous, without doubt, to make
the great diameter of the wound transversely, as done by Mr. Goodlad and
advised by M. Fonthein, than perpendicularly. These are the only general
rules that can be established on this first point. It is upon himself, his know-
ledge, and his peculiar ability, that the operator will be obliged to rely in fol-
lowing, modifying, or infringing them.
Second Stage. — The integuments being dissected and the flaps turned back,
the surgeon detaches the altered mass commencing at its superior part and on
its posterior edge, so as not at first to fall upon the carotid ; he ties all the
arterial branches as they are opened, or, if they are of inconsiderable size, fol-
lows the precepts of Zang, leaving them to be compressed by the finger of an
assistant, observing when about the margin of the maxilla or near the ptery-
goid muscles, to keep the edge of his knife rather backwards than forwards,
directed against the tissues to be extirpated rather than towards those which
ai-e to be preserved. When the handle of the scalpel is sufficient, it ought to
be preferred. With this instrument most of the lobes of the gland may be
torn loose and insulated, and disengaged from between the vessels, without
any risk of wounding the arteries, and the dangers of the operation are by so
much diminished. However, when it is certain that the adhesions to be
destroyed contain nothing important, the bistoury is to take the place
of the scalpel. By temng, the dissection is more certain ; by incision, it is
quicker, less painful, and more favorable in the sequel. Behind the ramus
of the jaw, the operator is to redouble his precautions. There, are located the
external carotid, completely enveloped with glandular granulations, in some
subjects, and the origin of the temporal and internal maxillary. Deeper, at
the apex of the parotid fossa, if any pedicle exist, or any portion that cannot
be removed by the handle of the knife, prudence dictates that a ligature be
passed around on the side of the sound parts before cutting them. Supposing
that during this operation a large artery, the external carotid for instance,
should be opened, or that its lesion appears inevitable, before proceeding fur-
ther in the operation it is laid bare towards its origin, that the ligature may be
applied low enough to prevent its being touched again during the operation.
If the muscles of the styloid process, the digastric especially, have not dege-
nerated, we should endeavor to preserve them. In the opposite c^se, they
are sacrificed without hesitation, as also the trunk of the facial nerve, which it
is useless to attempt to save when the entire parotid is disorganized. In the
end, it is possible that the gland may resist only at its summit; and notwith-
standing the tractions exercised by the left hand on the one part, and by the
handle of tlie scalpel on the other, this point holds firmly at the bottom of the
472 NEW ELEMENTS OF
wound. Then, for fear that it contain some large vascular trunk, it is best to
include it in a ligature and strangulate it as in the case of a polypus, conform-
ing to the advice of Hezel, and confining ourselves at the moment to the
excision of the free part of the tumor only.
Remarks. — The arteries which may have to be destroyed, are, besides the
carotids, the transversalis faciei, the temporal, the auricular, the mastoid, the
stylo-mastoid, the occipital, the internal maxillary, the inferior pharyngeal,
the lingual itself, and the facial. It is necessary, therefore, to tie successively
all these branches, if their common trunk has not been previously secured.
The blood which continues to flow afterwards, can only come from the veins,
and requires no other care than the application of a compress, if it do not
cease spontaneously. At first sight, the excavation which has been produced
has something frightful in it, but its depth alone does not prove that the whole
gland has been extirpated. In swelling, the ganglia which are in the centre
or at the borders of this organ, force it in every direction, produce in it atro-
phia, and cause it in some measure to disappear, so that after their removal, it
is very easy to be deceived, and to believe that the parotid itself has been extir-
pated. It is a remark on which Messrs. Murat, Cullerier, Richerand, and
Boycr justly insist, which it is important not to forget; and which allows us to
estimate at their true value the assertions of authors whose observation I have
noted above, and to understand how this operation can be performed without
producing hemorrhage, by dividing only the smaller vessels, &c. If the
wounds be but of few inches in extent, the flaps may be approximated, and
united by strips or the suture. But when it is very broad, by attempting to
close it immediately and fully, it is liable to purulent discharge, to simple or
phlegmonous erysipelas, and all their consequences, as was seen in the cases
reported in the name of Beclard and several others. After cicatrization the
patient may remain weak, and he should be apprised of it beforehand. The
motions of the pharynx, of the larynx of the tongue, of the jav/ itself, suffer
sometimes greatly from this operation on account of the division of the
muscles. Most frequently the division of the facial nerve paralyzes more or
less completely the eye lids, the ala of the nose, the labial angle, and all the cor-
responding half of the face. In time, however, the most of these parts recover
their powers, and it is rare in the end that the countenance does not resume
its former expression.
2. Ligature, — The cutting instrument is not the only means in the hands
of practitioners to destroy the schirrous parotid. Intimidated by the dangers
of hemorrhage, Roonhuysen, who had already proposed to substitute the liga-
ture, passed a double ligature deeply through the base of the tumor, and tied
its two portions separately, the one above and the other below, so as to produce
mortification of the diseased tissues by depriving them of all circulation.
M. Mayor recommends that it be first exposed, as if for its extirpation ; and
after insulating all the portion which makes the projection externally, it is
traversed, as by Roonhuysen, or rather it is drawn outwards as much as pos-
sible with a hook-foVccps, and a strong ligature is passed beneath its root, which
is gradually tightened by his chaplet-constrictor. In five or six days, says he,
the degeneration is entirely cut off or reduced to decay, without risk of the
lesion of any artery. In this manner he cured a girl, fourteen years old, of a
tumor which had existed for three years in front of the ear ; and another
OPERATIVE SURGERY. 473
person eighteen years old, upon whose person the gland extended from the
zygomatic arch to beneath the angle of the maxilla; and again, a third on
whom the morbid mass, eight inches long and four broad, was situated in the
parotid region. But whatever may be said by this author, these facts relate
rather to the extirpation of degenerated lymphatic gangliae than to that of the
parotid gland, properly called. I observe, besides, a disadvantage in this
method ; it is likely to remove but a part of the disease when it is deeply seated,
and if it be superficial, as the use of the bistoury then ceases to be formidable,
it loses much of its importance. However, in the first of these cases I would
willingly try it in combination with dissection. Without the trouble of ex-
tracting all the branches of the gland, one after the other, a strong ligature
which would include them en masse, and allow them to be gradually strangu-
lated, seems to offer a resource which has been too much neglected, as M.
Mayor justly complains.
3. Caustics, — The advice of Desault and of Chopart, who require that after
excising all the projecting part of the scirrhus the rest shall be destroyed with
hot iron or caustics, is assuredly of the very least value, and scarcely deserves
to be noticed. Cautery could not be useful in this operation, except to close
tlie mouths of vessels escaped from the ligature, and to consume some morbid
particles, if any have been left by the instrument against the intention of the
operator.
*^rt. 2. Submaxillary Gland,
No conclusive observation proves that the submaxillary gland ever passes
to the state of scirrhus or cancer. The cases which have been reported refer
to the conglobate glands which border on it, and are found between it, the
margin of the jaw, and the platysma myoides. Its induration in consequence
of chronic inflammation, in ranula, for example, is far from being equally rare.
Abscesses developed in the cellular tissue of the surrounding parts, and which
remain fistulous after being opened, also produce it. But however obstinate
it may be, this disease generally yields to other means than extirpation, which,
to me, does not appear altogether indispensable. Of the two cases of it which
were published in France some time since, the one which 1 reported and which
belongs to M. J. Cloquet, was a pure and simple case of the extirpation of
sub-hyoid ganglia; the other, related by M. Amassat, belongs probably to the
same class, and, by the way, it is far from being demonstrated that the ope-
ration in this case was absolutely necessary. Whether the disease is seated
in the gland, or the ganglia which surround it, the process to be followed in its
removal is nearly the same. Embraced as it were inferiorly by the concavity
of the digastric musckj and separated from the integuments by the facial vein
and the platysma myoides, the submaxillary gland rests superiorly against the
internal face of the jaw, and inwards against the hyo-glossus and the mylo-
hyoides muscles, upon the external face of which it sends one of its prolong-
ations. The facial artery coasts along its superior and internal side ; the
lingual nerve and artery pass beneath. Quite high up it receives the plexus
of the myloid nerve.
Manual — All that has been said of the form and direction to be given
to the incision in speaking of the parotid, is equally applicable here. The
CO
4T4 NEW ELEMENTS OF
patient is to have his mouth closed, the chin elevated, the head thrown back
and to one side ; the gland of the tumor is thus brought entirely in view. The
surgeon divides the skin at first from above downwards, from the margin
of the jaw to the os hyoides, and then transversely ; he dissects, detaches, and
turns back the flaps thus traced out; applies two ligatures upon the facial vein,
and divides it between them if it is too much in the way and cannot be kept
aside by a hook ; inserts a hook into the body of the gland and has it drawn
outwards and upwards, then backwards and downwards, while with short
strokes he detaches the inferior portion or the anterior moiety ; avoiding care-
fully the lingual artery and the concomitant nerve, he seeks posteriorly the
trunk of the external maxillary and ties it; has the hook carried forwards and
downwards; separates the morbid mass from tlie side of the tongue, and
removes it without difficulty. If it be preferred to commence by tying
the facial artery, the first incision is to be directed over it, and it h to
be looked for at the point which I have indicated in another chapter. It may
not even be tied at all if care is used to preserve untouched to the end tiie
point through which its branches penetrate the gland, and to embrace it as a
pedicle with a strong ligature. As for the dressing and treatment, we are to
act as after the extirpation of the parotid, always recollecting, that beneath
the jaw immediate reunion presents infinitely less danger, and that the whole
of the operation is incomparably less formidable than in the subauricular
fossa.
SECTION II.
Anterior Region.
Jrt, 1 .--Tliyroid Body.
Goitre or bronchocele is another tumor with which modern surgery has
been much occupied, and which is not to be attacked by surgical means until
after having been vainly opposed by iodine, the powder of Sency, and
the other pharmaceutical resources, extolled at the present day; and if it
should become so oppressive to the patient as to endanger his existence.
Caustics y which were employed for its destruction in the days of Celsus,
and since by a small number of practitioners, are no longer in use. The
seton which the elder Monro, Gerard, and more particularly Flajani, have
tried, or seen tried with success, and which M. Quadri, of Naples, recently
published as a new resource, does not deserve the same proscription. The
advantages to be derived from it are placed beyond doubt by a number
of authentic cases, and whenever, instead of hypertrophy, fungous or cancer-
ous degeneration, the tumor is formed by cysts of liquid or semiliquid
substances, its application is most rational. M. Quadri applies it in general
from above downwards with an instrument analagous to the needle of M.
Boyer, and rarely carries it beyond half an inch in depth for fear of wounding
the blood vessels. If the mass to be destroyed is very voluminous, he
passes through it two, three, and even four ligatures, at difierent points. The
goitre soon begins to shrink, and resolution, which is eifected gradually, con-
tinues in most cases, even after discontinuance of the seton and cicatrization •
of the wounds. The thyroid is often the seat of hard swelling, I have met
OPERATIVE SURGERY. ^5
with scirrhus in it. Burns and M. Wardrop, have there met with encephaloid
matter 2inA fungus hsematodes. But the facts brought forward by the Naples'
surgeon do not prove that in such cases the seton is able to triumpli over the
disease. Under these dreadful circumstances there have been proposed, liga-
ture of the bronchocele, its extirpation, or the ligature of the principal arteries
entering it.
Ligature. — To Moreau, surgeon of the Hotel Dieu, Valentine attributes the
idea of attacking the goitre by ligature. One of the patients thus treated
in 1779 was not relieved, the other was perfectly restored. The tumor in the
first was cancer, that of the second v/as of an adipose nature. The surgeon
passed a double ligature through its base, so as to divide it into two equal
parts, which he strangulated separately. Some years afterwards Desault had
also recourse to it, but it was to terminate an extirpation, the last stage of
which had become dangerous. Bruninghausen used it with complete success
in 1805, to destroy an enlargement about the size of an egg, which was situated
in front of the neck between the larynx and the sternum, of a young man
twenty-five years old. The science rested at this point until, some years
since, M. Mayor carried forward its boundaries ; a child twelve years old,
upon whom he operated in 1821 for a goitre of the size of an orange, at the
end of a month left the hospital in perfect health. On a man twenty-one
years of age, the tumor occupied the front and both sides of the neck, extend-
ing from the maxillary angles and the parotid region to very near the sternum
and the clavicles. Of the three lobes which composed it, the middle was as
large as the head of a foetus of seven or eight months. The whole mass was
nine inches in depth, and twenty-six in breadth beneath the jaw. The
general health of the patient was bad, and yet M. Mayor cured him
radically in less than a month. He was equally successful on a lady, of
Sackendorf, who had in vain consulted the most distinguished men of every
country, to free her of a tumor which had existed for nearly thirty years.
This tumor, which had not ceased to grow, occupied all the left side of the
neck, had pushed to the right the larynx and trachea, compressed the carotid
artery and internal jugular, and seemed seriously to threaten the life of
the patient. His process consists in laying bare the whole anterior face
of the bronchocele by a crucial or T incision ; then insulating it more or less
from the adjacent parts with the fingers or the handle of the scalpel; after-
wards to pass a strong ligature round the root of each of its lobes, or to
traverse its base with a double ligature, which permits it to be strangulated
upwards and downwards. Instead of one or two ligatures he sometimes
employs as many as four, which are then to embrace each a fourth or third of
the gland. As many constrictors are necessary as there are nooses of thread;
and it is to the chaplet-constrictor, as we may well guess, that he accords the
preference. From these details it is evident that the ligature here is but an
accessory means, a resource against hemorrhage, a kihd of make-shift, good
to be used when there is danger of wounding vessels of some importance ;
and that if it were certain that all the large arteries could be avoided,
extirpation with the bistoury would be much more advantageous. It is an
operation besides which cannot but be a serious one ; two of the patients ope-
rated on by M. Mayor himself sunk under it. It causes suffocation, angina,
difficulty of respiration, and frequently some of the symptoms of putrid fever.
476 « ' NEW ELEMENTS OF
Consequently I would not advise it, but with the condition of first detaching
the tumor with a cutting instrument or the fingers to the greatest extent
possible, so as to have a pedicle instead of a large base to strangulate ; with
the condition also of cutting: off the tumor without the knot, and not leaving it
to putrifj in the wound.
Obliteration of the Arteries. — Some practitioners were of opinion that by
tying the thyroid arteries they would probably obtain resolution of the goitre.
Burns refers the first idea of it to Mr. W. Blizard, of London. The patient
upon whom this surgeon operated, did very well for a week, but several
hemorrhages, and hospital gangrene soon exhausted him, and finally caused
his death. Since then, M. Walther, who conformed to the precept of the
English surgeon, in 1814, performed it with full success. To Mr. H. Coates
is also due another successful case. Mr. Earle and Mr. Green have not been
less fortunate; and M. Boileau, being obliged to tie the carotid for atraumatic
lesion, in 1825, had the satisfaction not only of saving his patient, but also of
seeing him cured of a goitre of many years' standing, Mr. S. Cooper, however,
informs us that a ligature of the thyroid vessels, performed by M. Brodie,
produced no diminution of volume in the tumor he wished to destroy. With-
out being very numerous, these facts are, however, sufficiently conclusive to
justify subjecting this mode of relief to new experiments. It ought particu-
larly to be tried in pure and simple bronchocele, or in hypertrophy of the thyroid
body. Instead of one or two, in my opinion the four thyroid arteries should
be tied, otherwise it is to be feared that the blood which is cut off on one side
may return by the other ; the more so, as the long continued irritation of the
parts has in general produced there a very decided development of the
vascular system. After all, the operation has nothing in it which should
deter the enlightened surgeon. If the natural pulsations of the vessels are not
sufficiently strong to serve as a guide to the instrument, each thyroid artery is
to be sought for at its origin from the carotid, tlie superior on the internal side
of this trunk, the inferior by following the rules laid down elsewhere.
Extirpation. — By extirpation the whole of the disease is removed, and the
patient promptly freed from it: but this operation is attended with so many
and such formidable dangers, that all the members of the old academy of
surgery, and the great majority of the authors of the present age, concur in
proscribing it. It seems to me probalile, however, that we shall soon have
cause to form a different judgment. Tliat in the time of Albucasis, a patient
who had submitted to it died of hemorrhage, is not very surprising ; and that
the young woman, mentioned byPalfm, sunk from the same cause during the
operation, is also easily imagined. Although one of the patients mentioned
by Gooch died, sinking, at the end of eight days, and to save the other it was
necessary for assistants to succeed each other constantly during a week, in
order to compress with the fingers without relaxation all the arterial mouths
which had been opened ; although an officer, whose case is told by Percy, died
also of hemorrhage, and the patient of M. Dupuytren survived but thirty-
five hours the removal of the tumor ; although the cases of extirpation brought
forward by Freytag, Vogel, Theden, Desault, Giraudi of Marseilles, M.
Fodere, and the barber who, according to Paradi, performed it with success
on his wife, are not all very conclusive ; although the girl more recently treated
by Klein was the next day seized with an apoplexy to which she fell a victim.
OPERATIVE SURGERY. 477
it would be wrong to condemn attempts which are intended to familiarize us
further with this operation. Bj combining it with the ligature, as practised
so successfully by M. Mayor, and at the same time by M. Hedenus, of Dres-
den, it cannot be doubted that much success may be derived from it in future.
The most complicated cases have not intimidated this last surgeon, who in
1822, had succeeded in six cases. His process differs from that of M.
Mayor, in his dissecting the bronchocele carefully with the scalpel to its whole
depth, and tying the arteries as soon as divided by the instrument; in this
also, that the ligature which he places the same as the surgeon of Lausanne,
but tics it as for the obliteration of a large vessel, has no other design
than to strangulate what he dares not cut, and to permit him to excise all the
morbid mass immediately and safely. For my part I will not decide on the
extirpation of a real goitre, until I am assured that it is complicated with no
lesion of the heart, no tendency to apoplexy, and that the surrounding lym-
phatic glands are sound ; nor until after having tried either the seton, after the
manner of M. Quadri ; the simple incision, advised by M. Fodere, and prac-
tised with success by M. Delpech; or, as advised byM. Rullier, an irritating
injection thrown into the cyst, if there be one; or the preliminary ligature of
the thyroid arteries; only at the earnest entreaties of the patient, and
when, instead of being merely a deformity, the bronchocele constitutes a disease
whose progress and nature threaten more or less imminently the life of the
patient.
Manual. — Suppose a goitre occupying every point of the gland. The pre-
parations are much the same as in removal of the parotid. The patient is laid
on his back, his head moderately bent back and held by assistants. Placed
on the right, the operator makes his first incision on the median line, com-
mencing above and terminating below the tumor; transforms this wound into
a crucial incision ; detaches the flaps and dissects them as far as their base ;
divides transversely the fleshy strips, and turns them back to their point of
attachment, if they are sound, or, if diseased, includes them in the subse-
quent excisions ; ties the vessels that are in the way; reaches, gradually, the
edges of the thyroid body, draws them towards him, tearing rather than cut-
ting ; finds, deeply seated, at their superior and inferior parts the four prin-
cipal arteries of the organ, insulates them, and passes round each a ligature;
avoids with all possible care the trunk of the carotids, the internal jugular
vein, the descendens noni, the pneumogastric, the great sympathetic, and the
cardiac nerves which are to be found a little further outwards, crossed by
numerous secondary veins ; then detaches the tumor, by its superior part, from
the sides and anterior face of the larynx which it surrounds and sometimes
deforms, by depressing the thyroid and cricoid cartilages, from which it is se-
parated only by the thyro-hyoid muscles, cellular lamellae, and some small
arteries which it is necessary to tie, furnished by the lingual or maxillary
branches ; returns towards its edges, which he raises and separates from the
oesophagus, then from the trachea near which are the laryngeal nerves ; in fine,
when it is only held by its inferior edge, if the venous plexus which issue
from it, and the thyroid artery of Neubauer, which is frequently to be
found there, cause its complete separation to be dreaded, he includes all these
objects in a ligature, or rather traverses its pedicle with a double ligature;
strangulates them as forcibly and as near their root as possible ; after which
478 NEW ELEMENTS OT"
he removes without fear the whole of the goitre. A dissection so painful
and so delicate cannot be quickly performed. The patient has need of
resting from time to time. All pressure on the trachea or the larynx ought
to be avoided with the greatest care, and the surgeon should keep in mind
that if the inspirations are not free, the blood accumulates in the veins and
flows in torrents under the least cut of the bistoury. Before proceeding
to the dressing it is necessary to tie the smallest arteries. As to the veins,
they will cease to bleed as soon as the patient, freed from restraint, can ex-
pand his chest freely and without fear. If it happen otherwise, they are to
be tied ; which, by the way, is far from inducing phlebitis as surely as some
modern observers contend. The convulsive movements, and even death,
whi<:h have sometimes occurred during the extirpation of tumors accom-
panied with great development of the vascular system, being attributed by
some to the opening of these veins, it has been supposed that bubbles of
air, penetrating thereby, have been carried to the heart and caused these
frightful eiFects. Experiments upon animals, related by M. Magendie; M.
Larrey, who declares that he saw a puncture of the external jugular prove
suddenly fatal, gave the first idea of this theory. An accident that hap-
pened at Hotel Dieu under the knife of M. Dupuytren, another of the same
kind experienced by M. Grsefe, and a third by Dr. Mott, have seemed to
confirm it. It is not on the neck alone that accidents of this kind have
been observed. M. Piedagnel relates the history of a man from whose
shoulder an enormous tumor was extirpated by M. Beauchene, in 1818.
The operation had not been completed when the patient exclaimed, there
is blood falling in my heart, I am a dead man! and he died, in reality. The
same happened to M. Clemot after removing a tumor from the breast, and two
patients upon whom he opened one of the axillary v6ins were on the point of
meeting the same fate. These observations do not, in my opinion, place the
matter beyond all dispute. The late experiments of M. Poiseuille, tend to
prove that if the absence of valves in the large veins of the neck renders it
possible, it is not so in the extremities and other parts of the body. The
patient of Klein, and the adult operated upon in 1 830, by M. Dupuytren, for a
thyrocele, also died suddenly, and yet there was no thought of referring this
occurrence to the passage of air through the veins. Thus, without denying its
possibility (at least when the veins, lost as it were in the midst of firm tissues
to which their external surface adheres and which they excavate in form of
canals, after their division remain patulous at the bottom of the wound), I
still think that this phenomenon requires to be confirmed by further observ-
ations. The surfaces being well sponged and the threads brought out at the
angles of the wound, it remains only to approximate the flaps and to close
the wound more or less completely. As in front of the neck the centre
of the wound is more elevated than its sides, I see only advantage in
attempting immediate union rather by adhesive strips or several stitches,
provided, however, that with the exception of the ligatures no foreign body
is obliged to be left under the skin. For the rest, the several parts of the
dressing should be light, and very softly applied. All compression in this
place would be dangerous, and a too great load of apparatus would occasion
an injurious degree of warmth. If the tumor includes but one side of the
thyroid, or, if independent of that body, it is situated on some other point of
OPERATIVE SURGERY. 479
the anterior half of the neck, the modifications to be adopted in the process I
have just described, are very trifling, and too easily conceived to render it
necessary to give them here at length.
Art, 2. — Air Passages,
§ 1. Broncliotomy,
By the term bronchotomy, the ancients intended to designate the artificial
and methodical opening of the aeriferous canal in its cervical region, and by
no means that of the bronchia as its etymolog}' would lead us to infer. At
present, as it is performed on different points of the respiratory canal, by the
word hronchotomy is to be understood the operation in general, while in its
special application it includes, tracheotomy y laryngotomy, and laryngo -tracheo-
tomy, Asclepiades of Bithynia was the first, I believe, who ventured to per-
form it. No one previous to Antyllus and Paulus Egineta, had described it.
C. Aurelianus, Aretaeus, and most of the Greek authors reject even the idea ;
on the one hand, because, according to them, a wound of the cartilages is
mortal, and on the other, because bronchotomy appeared to them only calcu-
lated to increase the inflammation of the trachea. Rhazes advises it only in
the case of imminent death ; and although, to prove that the divided cartilages
can reunite, Albucasis cites the case of a young girl whose throat was cut,
and who recovered completely ; and for the same purpose Avenzoar made
several successful experiments upon goats, it is yet necessary to come down
to 1 529 and 1543, to see it repeated by A. Benivieni and M. Brassavole. Only
since the time of Fabricius ab Aquapendente, have writers in general ad-
mitted its utility, and even necessity, under some circumstances. And they
have not always agreed upon the cases which require it.
Indications and Appreciation. — P. d'Abano, who called it sw^scanno^ioyi, and
after him Gherli of Modena, G. Martini, 6z:c., thought it indicated in every
case of angina tonsillaris or laryngea^ which threatened suffocation; but
although defended by Mead and Louis, their opinion, which by the way is as
old as the days of Avicenna, and was strenuously opposed by Cheyne, is
scarcely admitted any longer, but by Drs. Baillie and Fare. Purely inflam-
matory angina, however intense it may be, rarely goes so far as to require
such a relief; medicine possesses means to oppose it not less efficacious and
much less fearful. It can scarcely be comprehended how acute swelling of
the tonsils, for which Flajani did not fear to have recourse to it, can ever
require it. The same with greater reason applies to their cliroriic engorge-
ment, which with much less danger is always to be removed by excision.
When the tongue suddenly swells so as to fill the mouth and close the
istlimus of the fauces, Richter and B. Bell, who recommended it, certainly
forgot that two or three deep incisions on the dorsum of the affected organ
would cause its diminution, and probably they were not acquainted with
the observations of Delamalle on this subject. I can hardly believe that it
was not possible to dispense with it in the case in which Mr. Burgess lately
performed it; since there was but an inflammatory intumescence, produced
by a burn, at the bottom of the buccal cavity. Moreover, it is almost
universally admitted, since Desault, that it is not proper in the consequences
A*
480 NEW ELEMENTS OF
of submersion, and that in prescribing it in asphyxia of drowned persons,
Detharding was entirely mistaken as to the manner in which death is caused
under such circumstances. Nevertheless, Mr. S. Cooper, who considers it
more prompt and easy than the introduction of a gum-elastic sound through
the nose or mouth, is right in my opinion in maintaining that it should not be
proscribed without restriction. If the mouth is firmly closed, if the sound
does not strike the opening of the larynx, bronchotomy is better than nothing,
since prompt action is necessary, and air must be made to enter the lungs.
When we reflect on the difficulty of closing the glottis entirely with the tube
which we engage in it, and of preventing the insufflated air from escaping by
the digestive passages, in every case in which the surgeon thinks proper to
attempt artificial respiration, we must feel disposed to accord this operation
over the use of the catheter.
(Edematous Angina, that is serous enlargement of the lips of the glottis,
is a disease of which bronchotomy seems to constitute the remedy par excel-
lence. By supplying a passage for the respiration, it affords the physician time
to attack the disease by appropriate means, and to the organism the means of
extinguishing it, or at least of resisting its further advances. The antagonists
of Bayle, the first who speaks of it on this occasion, reject it under a pretext
which to me does not seem valid. Their permanent tube in the natural
passages, could not be left in the trachea for from eight to fifteen days without
danger ; while a canula, once inserted through an artificial opening in the air
canal, gives but little inconvenience. I think therefore, with Mr. Lawrence,
that in this species of disease, otherwise almost constantly fatal, it deserves
some attention, and offers a much better chance of success than scarifications
of the infiltrated parts, which have been proposed by some practitioners. The
patient, whose case is given by M. RouUois, of Mayenne in his thesis, and
who was operated upon at the hospital Saint Antoine, by M. Kapeler, in 1828,
died, it is true, at the expiration of thirty-six hours, but after having been
recalled as by.a miracle from death to life, and very probably because the
air could not be made to pass in sufficient quantity and without interruption
into the lungs. The subject mentioned in the supplementary journal was
more fortunate: he survived. A polypus, a tumor in the nasal fossae or
pharynx, the thyroid body or some lymphatic ganglia, swelled, indurated, and
large enough to prevent the passage of the air through the trachea, do not
render the operation indispensable except when there is imminent danger of
suffocation, or when it is impossible or too dangerous to attempt the removal
of the morbid mass. Sharp reserved it in some measure for these cases alone ;
for it did not appear to him absolutely necessary in the extraction of foreign
bodies.
Foreign Bodies, — At present it is chiefly to reach heterogeneous substances
of some consistence, which are often introduced into the larynx or trachea,
that this operation is willingly performed. It is used in this way for the ex-
traction of clots of blood which have fallen from the mouth or from a wound
of the larynx; lumbrici ; flies; portions of food, such as fish bones, bones of
poultry ; fragments of mushrooms, of apples, of chesnuts, or of acorns ; poly-
pus of the pharnyx ; a cherry, prune, or apricot stones ; a French bean, a grape -
seed, a pill, a filbert, a piece of gold, a piece of silver, flocks of wool or tow,
a bullet, a button mould, a pebble, a pin, a needle ; fibrous tumors, probably
OPERATIVE SURGERY. 481
syphilitic, such as M. Senn has recently described, developed in the interior
of the pharynx ; a piece of cartilage, of tendon, of wood, of iron, of mem-
braniform concretion ; in a word, of every body which in any way may be lodged
in the glottis or the trachea. When the presence of one of these bodies in
the respiratory passages is duly ascertained, in case it cannot be seized through
the mouth by the fingers or forceps, there is no Question of the advantages of
bronchotomy. In the case published by M. d'Arcy, although the accident
had occurred but a few hours before, the bean had already become trebled in
size. Although the primitive symptoms which the foreign body has occasioned
are partially calmed, it does not cease to be the less positively indicated. In
fact the monk mentioned in the Eph, des cmt. de la nat., and who did not dare to
complain at first, did not die phthysical until the expiration of two years. One
of the patients cited by Louis, was so well that he was regarded as almost cured ;
yet he sunk at the end of the third week. Another who lived several years
with a louis d'or in the bronchia, died at last in consequence of its presence.
Tulpius, V. D. Wiel, Bartholin, Pelletan, and M. Dupuytren, have also seen
in some cases, the foreign body permitting respiration to resume in some
degree its original ease, and causing death after the lapse of one or several
months; and even years. There are also some, which, after this lapse of time
have been spontaneously expelled : witness the rump of the fowl mentioned by
Sue. But these happy efforts of the organism so rarely occur, that it would
be imprudent to reckon on them, and bronchotomy should never be dispensed
with under such insufficient pretexts. Foreign bodies lodged in the oesopha-
gus, inflammatory swellings sometimes caused by wounds, injuries of the
neck, have also induced some practitioners to perform bronchotomy to prevent
suffocation and give time to subdue the principal disease. Habicot imme-
diately subjected a lad to it, who, in returning from a fair, had no other re-
source to escape robbers than to swallow all the gold he had with him, rolled
into a pacquet. In the same manner he successfully treated a patient, who,
covered with wounds, was on the point of perishing for want of the power of
respiration. We should evidently do the same when life is seriously threat-
ened by the presence of heterogeneous masses in the oesophagus, or the swell-
ing of the lips of a wound in the larynx, when it is not possible immediately
to remove in any other manner the cause of suffocation.
Croup or laryngeal and tracheal diphthentis, that horrible disease, the
nature and treatment of which have been made equally clear by the excellent
researches of M. Bretonneau, is one of those affections which it seems at
first may be opposed with the greatest advantage by bronchotomy. Yet, not-
withstanding the assertions of M. A. Severin, Bartholin, and some other
practitioners of the seventeenth and eighteenth century, who are said to
have employed it with the best results, the physicians of our day still
doubted, in 1825, that in the existence of the disease it was of great import-
ance, and that science had more than conclusive and authentic example
of cure that could reasonably be attributed to it. Those given by Mr. S.
Cooper, in his own name, or that of Mr. Lawrence, or M. Chevallier, by no
means prove that these surgeons observed the real croup. The case reported
in the name of Dr. Andree, by Bursieri, Locatelli, Michaelis, and White, is
the only one accompanied with details sufficiently circumstantial to partially
satisfy the mind. The view in which bronchotomy has been considered until
61
482 NEW ELEMENTS OF
the present day, does not permit us to draw much advantage from it in croup.
Indeed it is not understood how it can remedy inflammation or spasm of the
larynx, which, according to Royer-Colard, &c., in this disease bring on the
fatal termination, or pulmonary engorgement, any more than the reproduction
of the morbid product, which by this means is removed from tlie trachea without
influencing in the least its extension in the bronchia. Tn this particular. Dr.
Canon has certainly exaggerated its importance, while MM. DesruUes, Bland,
&c., are right in contesting its utility. But it is not to be considered in
this point of view. Subjects affected with diphtheritis die in a state of
asphyxia for want of the power of respiration. The asphyxia is constantly
caused by the presence of a false membrane, or swelling of the laryngeal
membrane, and never depends on a spasmodic affection, which the cartilaginous
texture renders impossible or insignificant in the large bronchia, the trachia,
and the larynx. Now, we are to resort to bronchotomy less for the purpose of
extracting membraniform concretions, than for gaining time and placing the
patient in a condition to breathe while means of cure are devised. M. Breton -
neau has proved, moreover, that after the trachea has been opened, calomel may
be pushed through with advantage, 6r even a solution of the nitrate of silver may
be carried down by a small sponge on the end of a slip of whalebone, and the
false membrane, followed even into the bronchia and diphtheritis of the trachea,
treated as he has done with so much success that of the throat. In this view
bronchotomy is a precious resource which should be employed whenever the
disease, occurring in the larynx or below it, cannot be reached through the
mouth with topical remedies, but which, however, has not yet passed below the
first bronchial divisions. Four unexpected cures are adduced in support of
this doctrine. In the month of July, 1825, M. Bretonneau being called to see
Mademoiselle de Puysegur, a child four years old, whose three brothers had died
of croup andwho was herself aff*ected to the last degree, opened the trachea
freely and introduced a canula through the wound ; false membranes escaped
in great number for several days; he blew in calomel in powder, which was not
borne well; afterwards the same substance mingled with water; and thus suc-
ceeded in saving this unfortunate child. In a boy, seven or eight years old,
whom I examined at Tours, in 1827', a month after his cure, and who in the
most advanced stage of the disorder had been given up for dead by his parents,
M. Bretonneau opened the trachea as before, and saw life return at the
expiration of several minutes ; he extracted numerous membraniform concre-
tions, and felt obliged a little later to introduce through a canula which he kept
in the wound, a solution of lunar caustic, by means of a small piece of sponge
fixed on the end of a slender bit of whalebone, and after various obstacles,
which were overcome as soon as perceived, the child was entirely restored.
Quite recently (October, 1831) the same practitioner was no less successful
with a third patient. The child, eleven years old, was looked upon as dead,
when M. Bretonneau was called to him. He opened the trachea immediately,
and after several casualties, which were met by the best conceived means,
the young patient was completely cured.
A similar success has just been obtained at Paris, by M. Trousseau. A boy
of six years and a half, was seized on the 21st November, 1831, with a violent
sore throat, attended with cough, hoarseness, and some fever. On the 23d, at
nine o'clock at night, three physicians met in consultation- They were
OPERATIVE SURGERY. 483
all of opinion that the child was affected with croup, and that death would
infallibly take place before two hours. M. Trousseau proposed tracheo-
tomy, and performed it on the spot. The trachea was opened, beginning
from the cricoid cartilage, to the extent of seven lines. Hemorrhage from
the veins ceased almost immediately. However, a considerable quantity of
blood fell into the bronchia, which the child immediately threw out by
the wound, together with fragments of false membrane- Respiration imme-
diately became perfectly easy. A flat canula, was then introduced, similar to
tlie one described by M. Bretonneau in his treatise on diphtheritis ; then twenty
drops of a solution of nitrate of silver were dropped into the bronchia (3J for
3J of water). This instillation was repeated every six hours for three days
and a half. Every hour twenty drops of tepid infusion of mallows was
thrown in. It was not until the fourth day of the operation that the
child ceased to throw up diphtheritic concretions. The canula was withdrawn
and cleansed three times a day. While in the wound it was cleared several
times every hour by means of a small mop of horse-hair. On the tenth day
the air began to pass freely through the larynx ; and on the twenty-fifth the
wound of the integuments was completely cicatrized. At present (January
1832) the child enjoys excellent health.
Other diseases in my opinion are susceptible of being advantageously modi-
fied by bronchotomy. Phthysis laryhgea for instance, and those chronic
phlegmasise which eventually produce a certain diminution of the glottis. The
air finding a free passage beneath, leaves the larynx at rest, and offers
no obstacle to the healing efforts of the organism. Besides, we thus have a
new passage tlirougli which topical remedies may come in immediate contact
with the disease. Horses affected with the hives, have also the glottis
diminished, and present to the observer experiments altogether in favor
of what I have just advanced. Two of these animals employed in a manu-
factory of red lead at Tours, recovered their ordinary state of health after a
large canula had been fixed in the trachea. M. Barthelemy, and other veteri-
nary surgeoas have given cases much similar. Applied to man, these data
have not deceived the expectations of practitioners. M. Clouet of Verdun,
instructed a woman, whom a fistula in the larynx and other disorders had
rendered liable to suffocation, to wear a similar canula for twelve years. Price,
of Plymouth, owed ten years of flourishing health to the same kind of assist-
ance. In 1824, M. Bulliard, restored to existence a young soldier whom a
chronic laryngitis, and not the croup as he supposed, had borne to the gates of
death, after several fits of suffocation, by placing in the larynx a canula which
the patient wore for fifteen months. M. Godeve was no less fortunate with
a patient affected, as he says, with an ulcer of the larynx, but rather as I think
with a swelling of the vocal chords, who discontinued the use of the canula
witliout inconvenience at the end of six months. A patient of Mr. White
wore one for two years. M. Senn of Geneva, mentions the case of a cliild,
ten or twelve years old, who was threatened every instant with imminent suf-
focation, in consequence of frequently repeated inflammations, and was cured
as by a miracle by means of laryngotomy and a canula, which was not laid
by until the expiration of eleven months. It was much the same with two
patients operated on by M. Regnoli, who had a real coarctation of the larynx.
In a word, bronchotomy is an operation to be tried always, or almost always.
484 NEW ELEMENTS OF
when a mechanical obstacle, from whatever part it come, tends to produce
asphyxia, by diminishing more or less the calibre of the respiratory tube.
It is really very little dangerous in its nature. If up to the present day it
has not been more frequently practised, it was for want of a correct view of its
mode of action in cases other than those of foreign bodies, of reflecting that to
re-establish respiration it was sufiicient to open any kind of passage to the
air, and of perceiving that if the artificial opening is sensibly less than the
natural passa^s, the lungs remain incapable of performing their functions
completely, and in this case the operation in a great measure fails of its
intention. On this point there is a truth placed beyond doubt by M. Bre-
tonneau, and likely to be attended with the most happy practical conse-
quences. In the case of one of the horses just mentioned the tracheal
canula was only six lines in diameter. When the animal became a little
fatigued it was panting and out of breath. A canula of an inch was sub-
stituted for the first, and the horse immediately breathed freely and was
able to bear the most violent exertions. In the little patients whom the
practitioner of Tours cured by bronchotomy, was the canula of itself too
small, or was its diameter diminished by concretions and mucosities ? If
the symptoms of asphyxia disappeared for a moment, we see that they
quickly returned. On the contrary, when it was cleared out or made larger
the child seemed to revive. The same peculiarities are found in the observa-
tions of Messrs. Bulliard, Senn, and Trousseau. Mr. W. CuUen, who omits
to credit this idea to M. Bretonneau, collected in 1S9.7 other facts no less
conclusive to support it, and render it prevalent in England. After all, on
this point every one may make himself a subject of experiment. Diminish for
example the size of the atmospheric column which naturally goes to the lungs,
take from the opening of the nose one-half or two-thirds of their dimensions,
by closing them with a quill or gum-elastic tube; respiration will not be
arrested, but it will soon become painful, and in proportion to the narrowing
of the passage. It is of importance, therefore, in having recourse to broncho-
tomy for the purpose of maintaining respiration beyond several minutes, to
open the air tube freely, and to leave in the wound a canula of sufficient
diameter. This leads us to inquire which is best, tracheotomy, laryngotomy,
or laryngo-tracheotomy. The ancients had not to discuss this question.
They had only to do with the opening of the trachea. That of the crico-
thyroid membrane was not employed until Vicq d'Azyr, who proposed it
before the end of the last century. Desault is the first who conceived tlie
idea of completely dividing the thyroid cartilage on the median line; and to
M. Boyer belongs that of incising at once from above downwards the encoid
cartilage and the first rings of the trachea.
A. Anatomical and Surgical Remarks. — 1. Larynx. Formed of solid carti-
lages, of muscles tense as chords, and of a membrane pliant as well as vascular,
the larynx is beyond the danger of all spasmodic contraction capable of dimi-
nishing its dimensions with any degree of permanence. But on the other
hand the accumulation of fluids in its internal membrane, the least tur-
gescence soon diminishes all its diameters, so as to endanger life. The larynx
is free posteriorly, where it forms part of the anterior wall of the pharynx ;
covered in front only by the skin and aponeurosis, on its sides by the sterno-
hyoid and thyro'-hyoid muscles, accompanied laterally by the trunks of the
OPERATIVE SURGERY. 485
carotids; separated from the os hyoides by a furrow, at the bottom of wliichis
found the thjro-hyoid membrane, which is pierced laterally by the superior
laryngeal nerve and an arterial branch. It presents on the median line the
prominence of the principal cartilage much more apparent in man than in
woman, and in adult age tlian in childhood ; and has lower down a slight
depression corresponding to the crico-thyroid membrane, which is crossed by
the artery of the same name, sometimes a little higher sometimes lower; with
another small prominence owing to the presence of the cricoid cartilage,
below which is found the thyroid mass, and the anterior face of wliich is
often covered with an arteriole, single or double, which descends vertically
from the cricoid arch towards the thyroid body. When it preserves its natural
proportions, it is much larger in the adult man than in individuals of different
sex or age (hence the dangers induced by inflammations before the age of
puberty), and receives behind and on its sides the termination of the recurrent
nerve.
Laryngotomy after the manner of Vicq d'Azyr, adopted at present by a
great number of surgeons, offers the undoubted advantage of being easier of
performance, of acting onl}^ on a membrane scarcely organized and very
superficially situated, of not exposing any vessel or any important part to be
wounded, and of leaving the glottis untouched; but on the one part it does
not produce an opening sufficiently large to allow passage to the instruments
required for the extraction of foreign bodies ; and on the other, tlie canula
which can be thus employed will rarely be large enougli to admit a
sufficient quantity of air. By imitating Desault, on the contrary, as has
been done in America and in England, as also by Mr. Whately, by an
incision from above downwards, and M. Blandin in 1829, no risk is run of
dividing a vein or artery of any size. It is t)ie only means of bringing in some
measure into view foreign bodies which lodge or are arrested between tlie
lips of the glottis, polypi, or other vegetations, whicli, as well as worms, may
be found at this part of the organ. However, although lesion of the vocal
chords, so much dreaded by those opposed to Desault, is easy to be avoided,
and moreover is but of minor importance, although the voice of patients
treated by this method has not suffered more tlian by every other, yet it only
deserves preference in the cases just pointed out; besides, the patient should
not be of an age to have the thyroid cartilage too much cliarged witli phos-
phate of lime. If the fear of wounding the vocal chords be an obstacle,
the surgeon may follow the advice of M. Fouilhoux, and divide the thyroid
cartilage on the side, and then open the soft parts of the glottis transversely
to avoid it. When the foreign body is below the larynx, or when tlie inten-
tion is to place a tube in the wound, it is evident that this process is not the
proper one; perhaps it would be possible always to supply it by another
operation lately proposed by M. Vidal, of Cassis, for opening abscess of the
glottis, and by M. Malgaine ; an operation, the idea of which no doubt arose
from the experiments of Bichat on the voice, and which consists in penetra-
ting through the thyroid membrane, and even the epiglottis, if it be too
difficult to reflect it forwards through the wound. However, this operation**
has something repugnant in it, at least at first sight, which induces me to say
iiothing further of it, although I have succeeded very well in experiments on
the dead body.
486 NEW ELEMENTS OF
Laryngo-tracheotomy, which usually leaves the thyroid body entire, and
exposes only the crico-thyroid artery to be cut, does not, like Desault's
method, permit us to see to the bottom of the larynx, and acts upon a point
too distant from the bronchia for foreign bodies not very movable to be easily
brought to the opening, and too near the glottis not to render the use of a
perpetual canula very dangerous ; so that, notwithstanding its inconveniences,
tracheotomy seems to me to unite more advantages under all circumstances
in which the process of Desault is not positively required.
2d. Trachea. — The trachea, a kind of cylindrical canal, which descends
to a level with the second or third dorsal vertebra, formed of a score of carti-
laginous rings completed at their posterior fifth by a fibro-muscular membrane,
rests upon the oesophagus, inclining a little more to the right than to the
left, and is covered first by the common integuments, secondly by the
cervical fascia, single above, bifoliated below, where adipose masses and vascu-
lar tissue, and then the sternum, separate it into two laminse ; thirdly, by
the isthmus of the thyroid body near the cricoid cartilage ; lower down by
the supra-sternal venous plexus, lymphatic ganglia, common tissue, and the
middle thyroid artery when it exists ; fourthly, by a last fibro-cellular layer,
which is sometimes wanting ; and fifthly, by the sterno-hyoid and sterno-
thyroid muscles placed a little laterally. Behind the inferior laryngeal
nerve, and at some distance further, the primitive carotids run along it, and
it is sometimes crossed by one of the thyroid arteries, which in that case runs
from one side of the neck to the other. In .children, particularly, the arteria
innominata covers nearly always its anterior face until beyond the limits of
the thorax, so that the right carotid leaves it very high up to take its place
quite on the side, and it would be easy to wound either in performing
tracheotomy, if this disposition were forgotten. I have also seen the left carotid
rise on the right, and pass in front of the trachea to reach its ordinary destina-
tion, and reciprocally that of the right side. Other vascular anomalies have
also been met with in this region, and merit no less attention than the preced-
ing. From all these considerations, it results that the trachea, though quite
superficial above where the thyroid body, which protects its lateral parts
almost solely separates it from the integuments, becomes deeper in proportion
as we descend or incline towards the chest, following the thoracic concavity
of the spine, and at the inferior part of the neck it must be sought for at an
inch below the skin. The cartilaginous rings which compose it should be
sufficient of themselves to banish the idea of spasmodic contractions, which
have been so gratuitously attributed to it in croup. The membranous and
almost fleshy structure of its posterior portion, which rests on the oesophagus
and partially embraces it, explains how foreign bodies, lodged in the canal
of deglutition, have sufficed to cause suffocation, or pass into its interior and
render bronchotomy necessary. To conclude, the great mobility it enjoys,
if care be not taken in attempting to open it, causes it to be very easily pushed
aside, so much that the instrument strikes on the primitive carotid, as
happened in a case mentioned by Desault, in which a student of medicine in
asphyxia was thus destroyed by one of his companions in an attempt to save
him.
Examination of the Methods, — Those authors, who in ancient times recom-
mended bronchotomy, confined themselves, like Antyllus, to a transversa
OPERATIVE SURGERY. 487'^
division in the middle of the neck, of the integuments and the space between
the third and fourth rings of the trachea. J. Fabricius was the first to propose
the performance of the operations by two separate stages ; first, to incise tl^e
soft parts from above downwards on the median line, and then to open the
wintlpipe, as practised by the ancients. He l^ft in the wound a straight canula
furnished with wings. Casserius slightly curved his canula, which, according
to Solingen, should be flattened ; its external opening Moreau covered with
a sindon, and Garengeot with a piece of muslin, to prevent foreign bodies from
entering the trachea. To prevent its obliteration, and the necessity of re-
moving it for the purpose of cleaning it, G. Martine found it useful to employ
two, one within the other. Ficker, who adopts the idea of Martine, requires
the external canula to be of silver, the internal one of gumelastic, and that
both should have a certain degree of curvature ; in fine, some moderns have
maintained, with Ferrein, that the barrel of a quill may advantageously supply
its place. The manner of introducing this canula and fixing it has not been
less various than its form. Sanctorius inserted it with a trocar, and Dekkers
carried it into the trachea, dividing the skin also with the same instrument.
Moreau made a passage for it between two rings with a simple lancet, and
Dionis carried it in upon a stylet. That of Bauchot is very short, flat ; and its
inventor, who used besides a kind of crescent mounted on a handle for fixing
the larynx, had, like Dekkers and Sanctorius, a stylet of tlie same form, sharp
at its extremity, to pass through the skin and enter at once the trachea.
Richter bent Bauchot's instrument into a circular arch for the purpose of render-
ing it more tolerable ; and maintains that by the wound of the trachea being
immediately filled by the canula, hemorrhage is much less likely to occur than
in previous incision of the tissues. But this is an error, and notwithstanding
what has been said of it by Bergier and B. Bell, all these modes of entering
this passage with a single stroke are at present generally and justly pro-
scribed.
The dread of wounding the cartilaginous arches, revived by Purmann, no
longer exists. Heister has satisfactorily demonstrated that they may be di-
vided without the least risk. Virgili, of Cadiz, was obliged to divide them as
far as the sixth in a soldier, to rescue him from the danger of suffocation, which
the ordinary incision was about producing by determining a flow of blood into
the trachea. Instead of a canula he kept in the wound a plate of lead bent on
its edges and perforated with holes. To extract the half of an acorn Wendt
did not hesitate to cut through three of the cartilages ; and Percy advises on
this head to use scissors instead of the bistoury, which, however, is much more
convenient, and preferred with reason by almost every practitioner. My own
opinion on these diff*erent modes of proceeding has no doubt been already
guessed. In the first place I would banish all transverse incisions. In the
case of a foreign body the division of the space between two (Cartilages
cannot be sufficient ; and if the operation is to restore the power of respiration,
such a wound will never be large enough. If further proof be necessary, a
subject recently operated on in a large hospital will furnish it. The opening
of the trachea had been well made, the canula was properly placed, but it was
a portion of a gumelastic catheter, and the patient being obliged to take in air
by so small an orifice was only half delivered from the suffocation for which
bronchotomy was performed. In the first case canulse and perforated plates
488 NEW ELEMENTS OF
are useless. When the trachea is free the wound is to be united or permitted
to close. If the foreign body is Movable the air from the lungs may force it
out. If it do not spontaneously present at the wound it is to be sought for
with slender curved forceps, or some other appropriate instrument, in the
direction of the bronchia. When it is not possible to reach it or meet with
it, it is to be left, the wound kept open, and the patient watched. The next
day, or the one succeeding, it will generally be found on the lower surface of
the apparatus. Desault, Pelletan, and M. Dupuytren, have seen escape thus
a fruit stone, a bean, a piece of money, &c. ; and the needle which M. Blandin
could not succeed in seizing, after cutting the thyroid cartilage, also came
away in this manner. In the second, the canula is indispensable; but as no
author had made known the importance of a large and permanent opening,
none of the tubes which have been proposed are proper for it. That of M.
BuUiard is cylindrical, long, and very curved. M. Bretonneau has succes-
sively formed them of different shapes. The canula he used in the case of
Mmslle. de Puysegur was double like that of Martine, flat, a little concave
on its inferior edge, and four lines broad in its greatest diameter. The one
he employed in the patient whom I saw, was formed of two parts, one supe-
rior the other inferior, which he placed separately in the wound, and which
being united represented an instrument similar to the preceding. Two lan-
guets, in the form of a finger nail, which come off above and below at nearly
a right angle, fixed it very firmly in the trachea, and permitted a circular fold
of linen, pierced in the centre, to be placed between its exterior end and the
integuments of the neck, and which could be opened or closed at pleasure by
means of a kind of hinge. This piece of linen fulfills two important indicati(ms ;
by closing it with more or less force it compresses the backs of the two gutters,
which by their union form the canula, forces them to close within each other,
and in this manner reduces to any desirable degree the diameter of the artifi-
cial tube. According to the thickness given to it, it lengthens or shortens the
canula, and keeps its inner extremity exactly applied against the internal face
of the organ, prevents it from wounding the interior of this canal, and makes
the same tube answer for patients, the thickness of the walls of whose necks
may be very different. When in its place, if it is desirable to enlarge it, or
when any foreign body tends to obliterate it, we have only to pass into it
another canula larger, but not jointed, which is withdrawn and reintroduced
without deranging any thing else.
Whether a canula is to be used or not, some persons have proposed not only
section of the cartilages of the trachea, but also to cut out and remove a
portion of the anterior wall of the canal. It appears that veterinary surgeons
have often done so. Dr. Andree seems also to have followed this process,
which is formally recommended by Mr. Lawrence, Mr. Porter, &c. But it is
a precaution at once unnecessary and dangerous : unnecessary, as pure and
simple incision always permits the introduction of an artificial tube ; and
dangerous, because if it should become advantageous to close it, there will
result as a necessary consequence an incurable contraction of the diameter
of the respiratory canal. Consequently, the process of M. Colineau to effect
this loss of substance, and at the same time render all kinds of hemorrhage im-
possible— a process which consists in piercing the trachea by means of a
sharp plate projecting from the circumference of a flat disk of copper heated
OPERATIVE SURGERY. 489
to whiteness, fastened on a long handle — ^has not in my opinion any useful pur-
pose, and should be left unapplied. The advice of Messrs. Carmichael and
White is directed to the same end.
Manual. — Th£ apparatus consists of a straight or convex bistoury, a probe-
pointed bistoury, one or more canulas supplied with ribands and every thing
necessary to fix them, a forceps with rings, and a polypus forceps very slender,
several single ligatures and needles, hooks or probes bent into crotchets, and
various pieces of dressing. The patient is to be laid on his back, and to have
his head moderately bent back. Verduc has well explained, that by having
the head bent far backwards respiration is rendered more difficult, a remark
which applies to all the modes of performingbronchotomy. Placed on the right,
in order to cut from above downwards, and not from below upwards, as
directed by some, the surgeon takes hold of and fixes the larynx with the left
hand, while with the right, using a straight or convex bistoury, he divides the
tissues.
1. Tracheotomy. — In order that tracheotomy should be well performed, it is
necessary that the wound of the soft parts extend from the isthmus of the
thyroid, that is, from the boundary of the cricoid cartilage until quite near the
sternum. Beneath the integuments and fascia are the blood vessels, which are
to be tied as soon as divided ; the veins of the thyroid plexus, which are also
to be tied when it is not possible to avoid them ; and the middle inferior thyroid
artery, when it exists, which it would be dangerous to wound. Arrived in front
of the trachea, if the venous blood flows abundantly and there is no urgency,
we may suspend the operation from twelve to twenty -four hours, after the ex-
ample of M, Recamier, and some others; or at least wait some minutes for
respiration to cause the hemorrhage to cease : but if the case is urgent we are
to pass ligatures round the bleeding vessels, or even proceed to open the air
canal itself. Although the straight bistoury held as a writing pen is sufficient
to effect this opening, which should include at least the fourth, fifth, and sixth,
if not the seventh and third cartilaginous rings, yet there are practitioners
who prefer the probe-pointed bistoury to continue it after the puncture. In
this I see no advantage or disadvantage : should even the point of the instru-
ment touch the posterior wall of the respiratory tube, which appears to be the
cause of dread, there probably would not result much danger. This part of
the operation being over, a different course is to be pursued, according as the
intention is to extract a foreign body, or to relieve suffocation caused by
a lesion of the pharynx. In the first case, if the body is not immediately
expelled by the efforts of the patient, but presents at the wound, the operator
is gently to separate the lips of the wound with the forceps or hooks, and
endeavor to extract it with an appropriate instrument. When it is fixed in the
direction of the bronchia, wliich, as Favier has shown, is rather rare, there is
carried with all possible precaution in this direction a proper forceps, or rather
a small curette, to hook or grasp it. If these attempts prove fruitless they
should not be too often repeated. A number of cases are given, in which
foreign bodies, which no attempt could discover, afterwards came away,
of themselves, and have been found among the dressings. If the intention of
the surgeon is only to establish artificial respiration he immediately inserts the
canula, taking its inferior half, if he uses Bretonneau's, and carrying it into
the trachea, while with a peculiar kind of forceps, with beaks very flat
62
490 NEW ELEMENTS OF
and bent into the shape of a Z on their inferior edge, he opens tlie wound ;
he then fixes the other half, and applies the linen shield between the shoulder
of the instrument and the neck ; lines its interior with the other canula pre-
pared for the purpose ; carries the two ribands attached to its extremity to the
nape of tlie neck ; brings them back above it to make a second turn, and ties
them below it in a bow-knot. If during the operation venous hemorrhage
should be too abundant, and resist ordinary means, we sliould not be fright-
ened and quit the patient, as was done by Ferrand in a similar case. If the
patient enjoys his reason he should be soothed, and made to breathe as freely
as possible, and the blood will soon stop of itself. If it escape into the
trachea, and give rise to unfavorable symptoms, it will be a further motive to
imitate Virgili in opening largely and unhesitatingly the respiratory tube.
We may also, like M. Roux, if danger is pressing, place the mouth over the
wound and suck out the fluids which threaten suifocation.
2. Thyroid Laryngotomy. — When the larynx is to be opened, the incision
should commence at the projecting angle of the thyroid cartilage, and descend
a- little below the cricoid ; not requying to be as long as for tracheotomy.
The surgeon cuts successively through the skin the subcutaneous layer and
the facia; separates the thyroid muscles; carries the end of the forefinger
upon the crico-thyroid membrane, endeavors to feel the artery of the same
name; raises or depresses it with the nail, according as he intends cutting
above or below ; plunges his straight bistoury perpendicularly into the mem-
brane, guiding it on the finger nail, turning its edge upwards or downwards,
according to the side to which the arterial arch may have been pushed, and
there makes an opening of proper dimensions.
S. Laryngo -tracheotomy. — To transform the preceding operation into laryn-
go-tracheotomy we have only to use a probe-pointed bistoury instead of the
straight, and to enlarge the wound from above downwards by dividing the
cricoid cartilage and the first rings of the trachea on the median line. The
same instrument carried from below upwards, may also serve very well for
separating the two halves of the thyroid cartilage according to the plan of
Desault. Supposing that in spite of every precaution the crico-thyroid artery
be cut, and it should chance to prove the cause of a harrassing hemorrhage,
it may be easily tied on the right and on the left; and I am astonished
that a vessel of such little importance should have caused so much anxiety.
The little finger inti'oduced in the wound first seeks for the foreign body, and
then serves as a conductor to the forceps or any other instrument that it may
be necessary to employ. . When that is removed the wound is immediately
to be closed, and tlie cure is in general very speedy. When, on the contrary,
it cannot be found, the wound is left open and treated as in tracheotomy. I
do not think that the suture advised by some authors and practised by Herold
should ever be used, notwithstanding the opinions of MM. Delpech and
Serre. The patient mentioned by Wilmer, who had been thus treated, died
suddenly on the fifth day of the operation. It is only proper in this case to
solicit the flow of blood or other fluids, either between the air tube and tissues
which surround it or the interior of the canal itself, and the other retentive
means are always suflicient for the union of a wound like this.
4. TTiyro-hyoid Laryngotomy^ — After laying bare the thyro-hyoid mem-
brane on the median line, by an incision of two inches in extent, it is less diffi-
OPERATIVE SURGERY. 491:
cult than may be imagined to reach the superior vocal chords, by dividing it
transversely above and a little behind the cartilage to which it is attached. A
bistoury, entered at this point from above downwards and from before back-
wards, traverses the root of the epiglottis and immediately falls into the larynx,
the finger or forceps clearing a way, which may be enlarged at pleasure, and
which allows a full examination of the glottis without deranging either the
vocal chords or the cartilages. No artery of any size, and no important nei-ve
can be wounded. The laryngeal branch of the superior thyroid and the cor-
responding nerve, are at a sufficient distance from the median line to be easily
avoided, and no venous plexus is to be found at this point. The wound which
results will have some tendency to remain open, but it is probable tliat in the
living subject inflammation will soon approximate its edges, and cicatrization
take place without difficulty. Let me add, that if bronchotomy often fails of
success it is because the operation is too long deferred, tliat it is rarely decided
upon before pulmonary engorgement has rendered the preservation of life
almost impossible, and that in reality there is very little danger in the opera-
tion. When it is performed for croup, and to permit remedies to be dropped
into the trachea, the consecutive treatment forms its capital point. On this
point I can but refer to the Treatise of M. Bretonneau and the observation
of M. Trousseau,
§ 2. Branchoplasm,
If it happen that after wearing a canula a long time in the week, or that in
consequence of any wound whatever the patient retain a fistulous opening to
the air passages, he may be subjected to the ti'eatment of fistula in general,
and if nothingelse will succeed it will be allowable, as M. Dupuytren has once
done, to resort to the process of cheiloplasm, and particularly that of M.
Roux. A cutaneous flap turned back from below upwards, rolled as a stopper
and fixed in the fistula by two stitches, in a patient upon whom I have just
t»perated, is another resource which in my opinion ought not to be disregarded.
§ 3. Catheterism.
In new born infants, or at any other period of life, catheterism of the larynx
is an operation too simple to require a longer description. While one hand
conducts the instrument through the nose, or rather through the mouth, one or
two fingers of the other carried into the fauces, take hold of its extremity,
direct it into the glottis, and prevent its going towards the oesophagus.
^rf. 3. — Jilimmtary Passages,
§ 1. Catheterism,
Various affections render necessary the introduction of a sound or catheter
into the oesophagus. It is used as an exploring, extracting, or repelling means,
as will be shown when we come to speak of foreign bodies ; it is an indis-
pensable operation for entering the stomach, or when food or remedial sub-
492 NEW ELEMENTS OT
stances are to be artificially introduced, and lastly, it may be employed in
the treatment of certain diseases of the oesophagus itself. The performance
is easy and in the power of every one. It may be effected through the nose
as well as the mouth, with metallic instruments of proper curvature, and par-
ticularly with flexible bodies ; such as canulae of gumelastic, bougies, whale-
bone, rods &c.
jBy the Nose. — The first method, that of passing through the nasal fossae,
for a long time adopted as the best, at present is almost generally abandoned.
It is often difficult and fatiguing to the patient, and should only be retained
as an exceptional method. If the catheter is stiff, its curve scarcely allows
it to go further than the summit of the pharyngeal cavity, and consequently
hardly permits it to enter the oesophagus ; if straight and flexible, it impinges
against the spinal wall of the back part of the mouth, so as to he not always
easily disengaged. This way is better than none, hov/ever, if the other be not
practicable. The sound held in the right hand as a pen, is carried through
the nostril in the same manner and with the same precaution as for catheterism
of the Eustachian tube, except, that instead of being turned outwards or in-
wards, the concavity of its beak ought rather to look downwards. By means
of the index finger, or a blunt hook passed into the mouth, the operator reaches
its extremity as soon as it arrives at the upper part of the pharynx, depresses
it a little with the left hand, while with tlie right he continues to push it for-
ward ; he thus directs its point in the axis of the oesophagus, avoiding with
care the entrance of the larynx, and rubbing too hard against the parieties of
the organ; advances gradually, stops at the least difficulty; changes a little
the direction of his efforts, withdraws the instrument in some degree to push
it in another direction if he meet any resistance ; and descends to a greater
or less depth, according to the indication to be fulfilled. Supposing a straight
gumelastic tube cause some embarrassment, nothing will be easier than to
overcome this difficulty; it is to be carried until on a level with the glottis, by
means of a bent stylet it is then to be withdrawn from the sound, and the pro-
cess is then to be conducted as above.
Through the Mouth. — Whatever be the mode adopted, the patient is to be
seated on a chair and held as in all operations on the face. When he pene-
trates by the mouth, the surgeon depresses the tongue moderately with the
left index finger, which he carries, if he can, as far as the epiglottis, so as to
keep it as a guard against the deviations of the instrument on the side of the
respiratory passages ; glides the sound or catheter along the radial edge of tliis
finger, following the dorsal face of the tongue ; enters without difficulty the
oesophagus if it has the least curvature ; hooks the extremity in the contrary
case with the directing finger to oblige it to follow the axis of the canal, and
at length carries it as far as he judges proper. When circumstances require
it to be left in place after the operation, it is inclined to one side and laid in
any vacancy which may have been left by the extraction of teeth and fixes it
at one of the labial commissures by means of a riband carried round ihe head.
Although introduced by the mouth, if its presence is likely to fatigue this
cavity too much, nothing prevents, as judiciously remarked by M. Boyer, the
external part from being brought through the nose. For this purpose, after
being placed, it will be sufficient to attach it to Bellog's, or any flexible sound
introduced through the nostril, and draw it by means of a thread previously
ePERATIVE SURGERY. 495
fixed to its extremity, as in plugging of the nasal fossae. Unless the oesop agus
be devious, contracted, or deformed, the operation is ordinarily very simple.
There is no risk of injuring its parietes, of taking a wrong direction, or of
piercing it, as happened to the surgeon mentioned by Charles Bell, unless we
act with extreme imprudence, or a force that no experienced man would
attempt to exert. The finger being used for following the sound beyond the
epiglottis, it cannot be very difficult to knov/ if by chance it has descended
into the larynx, as seems to have been the case in the patient mentioned by
M. Worbe. A lighted taper presented to the orifice of the instrument, the
almost impossibility of penetrating further than the bronchia, or still better the
injection of a few drops of liquid, which would not fail to produce cough, &c.,
would soon afford a certainty on this point.
The presence of a foreign body in the cEsophagus is not borne by all subjects
with indiff*erence. In some it produces inclination to vomit, irritation, and
sometimes even fever. When more serious symptoms arise, whatever may
be its utility, it is to be withdrawn, and replaced some time afterwards if re-
quisite. One of its most formidable disadvantages, although authors have
scarcely noticed it, is, that either by its beak, or by the convexity which it is
forced to assume, it exercises greater pressure necessarily on some points of
the posterior wall of the organic tube than upon others. This pressure, slight
as it may appear, being uninterrupted, is of a nature to produce at first a
purulent discharge, then ulceration or an eschar, and finally a perforation.
The possibility of such an occurrence it is difficult to call in question, when
we know that the tip of a simple gumelastic sound has determined them more
than once upon the rectal side of the bulb of the urethra^ I fear too that the
patient, in whom the oesophagus was found ** destroyed for the extent of two
inches at least, at an inch and a half above its passage through tlie diaphragm" —
a patient who had been treated by means of dilating bougies with apparent
success by M. Carrier — was really its victim.
Stricture. — Since Mauchail established the analogy between coarctations
of the urethra and those of nearly all tlie mucous canals, surgeons, have at-
tempted, at various times, to apply to strictures of the oesophagus nearly all
the treatment useful in those of the urinary canal. Mechanical dilatation is
one of the first attempted to be employed. It was advised by MM. Riche-
rand and Dupuytren, and once put to the test by MM. Carrier and Jallon
upon a merchant of Orleans, who for a month was better, but sunk in the end
with an ulcerous destruction of the canal of deglutition ; applied by M. Boyer
in 1797 in the case of a woman who derived but little advantage from it; and
by M. Sanson on a patient who, after obtaining considerable relief, wished .
to leave the Hotel Dieu, under the belief that further treatment was not re-
quisite ; it seems to have been attended with complete success to Migliavacca,
cited by Paletta, to Mr. Home, Mr. Earle, and Mr. Mcllvain, The catheter
is the instrument for effecting it. Bougies, whether emplastic, elastic, conical
rather than cylindrical, or still better hollow catheters, employed so as to be
able gradually to increase their size, should be here managed with the same
reserve, and the same prudence as in the urethra ; but the canal being larger,
or requiring to be brought to greater dimensions, the volume which it is at first
necessary to give to these instruments has made it desirable to substitute for
them other apparatus. That of Mr. Fletcher, curved, slender, and made of
494 ' NEW ELEMENtS OF
metal, is formed of three branches, which a central staff, armed with a head,
separates or approximates at pleasure. After being introduced beyond the
stricture, the movable axis is drawn back, so that the branches insensibly se-
parate to the degree which the surgeon thinks proper. Though ingenious as
it may appear, this instrument should be rejected. It is from equal com-
pression, and not only at these points of the constricted circle, that dilatation
offers a prospect of success. It is most particularly necessary that this indi-
cation be exactly fulfilled, which Mr. Fletcher seems to have entirely forgot.
The air dilator of Mr. Arnott, and the flexible seton carrier recently devised
by M. Costalat, to reach deep strictures of the rectum, and particularly of the
urethra, will have incontestible advantages over it. I will recur to these under
the articles urethra and rectum. Many surgeons have also directed their
views to cauterization. Although this mode of treatment has not yet been
tested among us, and M. Boyer has deemed it necessary to proscribe it for-
mally, with the conviction that no experienced and prudent surgeon would
be bold enough to attempt it, it is not so elsewhere. In his excellent work
just published, on Chronic Affections of the (Esophagus, M. Mondiere shows
that it has been employed in Italy, England, and America. A flexible staff,
armed with a piece of lint soaked in a caustic liquid, was carried by Paletta
as far as the stricture, and the patient, who died some weeks after, was at first
relieved. Rejecting justly all fluid substances, Sir E. Home preferred the
nitrate of silver, and has used it seven times. Four of his patients were cured,
and the other three sunk under the natural progress of their disorder. Of three
cases reported by Mr. Andrews, of Madeira, only one did well, the two others
could not be saved. Lastly, Messrs. Ch. Bell and Mcllvain have declared
in its favor, as Darwin had done before, and appear to have used only the
nitrate of silver. The difliculty that first presents is to know the nature of
the stricture to be treated. Those which depend on chronic phlegmasia, indu-
ration, or a lardaceous transformation of the mucous coat, or the adjacent
layer, admit of the trial of cauterization ; but how distinguish them from lesions
caused by tumors, cancerous or fungous degenerations, ulcers, aneurisms,
polypi, &c.? The urethra being as it were not subject to any but the first,
does not occasion this kind of embarrassment. Its small diameter, its super-
ficial position, and the arrangement of its parietes, render its mechanical dila-
tation easy and almost without danger. The oesophagus surrounded by
yielding tissues, and naturally very dilatable, is fap from presenting in this
point of view such advantageous circumstances. In holding apart the sides
at the contracted point, bougies merely throw outwards the projection which
tends inwards, and the disorder returns almost immediately on the suspen-
sion of the treatment, which therefore is only palliative. As to the nitrate
of silver it is less in the character of a caustic than of a modifier of the morbid
condition of the part that I would be willing to employ it. In this view the
exactness with which we touch one point rather than another, is less important
than may be thought. It is, for the rest, a subject which will come under the
treatment of the urethra.
§ 2. Foreign Bodies*
Incision into the "oesophagus, first promulgated by Verduc, formally
OPERATIVE SURGERY. 495
proposed by Guattani, practised for the first time by Guattani in 1730, and
since by Roland, is an operation which is only applicable to two particular
cases ; first for the extraction of a foreign body, which, by its presence in
the CESophagus, endangers more or less the life of the patient; secondly,
for the artificial introduction of nutritive substances into the digestive
passages in case of impassable stricture of the inferior part of the pharynx.
In the first case, before proceeding to oesophagotomy, every means should
be tried to make the foreign body return by the natural passages, unless it is
of such a nature as to be pushed into the stomach without danger. A crust
of bread, a piece of tripe, large lumps of hard and coriaceous food, skin, a
slice of frwit, a sugar-plum, a morsel of cake, the rind of bacon, a whole egg,
a chestnut, a pear, a fig, and all solid substances which enter into tlie compo-
sition of food, may lodge in the oesophagus and give rise to serious accidents.
However, as these various bodies are more or less soluble in the juice of the
digestive passages, it is rare that they do not in the end descend into the
stomach. Pebbles, pieces of glass, fish bone, a piece of coin, a knife handle,
a fork, and a thousand different foreign bodies, of which the memoirs of
Hevin and Sue contain so many examples, are much more dangerous,
although the organism has more than once triumphed over them without
assistance. They tear or contuse the parts, and produce inflammations and
abscess and horrible pains, which have often no end but death. To the
numerous facts already given by authors, it would be very easy to add a host
of others. MM. Gibert, Murat, Bard, &c., have recently added to the
list, and practitioners meet with new cases every day. Thus, Dumortier
has seen the presence of a piece of money in the oesophagus produce perfora-
tion of the primitive carotid; and M. Begin gave, in 1828, the case of a
soldier, in whom the trunk of the thoracic aorta was opened in the same
manner by a five-franc piece. When their presence is evidently capable of
doing injury, and when the organism is unable singly to remove them, three
modes may be employed before proceeding to open into the oesophagus. To
push it into the stomach, to force it to return by the natural passage, and to
prevent, or meet with energy if they already exist, the symptoms which may
arise.
1st. Propulsion. — Only those bodies should be pushed into the stomach
which, being too difficult to remove by the mouth, are not dangerous to the
patient if once out of the oesophagus. Water, swallowed in abundance,
large mouthfuls of bread, beef, buiscuit, figs turned inside outwards, prunes
freed from their stones, pieces of sponge tied to a thread, long bougies lubri-
cated with oil, slight blows on the back with the fist as recommended by De
la Motte, and rarely omitted by common people, and I know not how many
other means have been proposed and successively practised with advantages
more or less marked, and often again without any kind of success. In this
case, the leaden staff of Albucasis and Rhazes, tlie ball of the same metal
cast and fixed on the end of iron, silver, or brass wire, so highly approved by
Mesnier, Verduc's silver rod terminating in an olive, the curved sound, &c.,
are far from always succeeding. In all this I can see scarcely any thing but
the pear -headed staff generally used since A. Pare, and the ball of lead,
which is really worthy of any confidence ; still will it be necessary that both
these instruments be made with flexible rods, capable of following with-
496 ^ NEW ELEMENTS OF
out difficulty the tortuous form of the mouth, pharynx, and oesophagus,
yet with sufficient solidity however to prevent their breaking during the
operation.
2d. Extraction. — When the fingers cannot reach the foreign bodies engaged
in the pharynx or oesophagus, there should be used long forceps, a little curved ;
like the urethra forceps of Hunter for example. The crotchet, or wire hook
of Reviere or Perrotin exposes the tissues to be torn upon its being withdrawn,
as was experienced by Petit, of Nevers. By tipping it with a button, Sted-
man really improved it; and M. Dupuytren, who substituted a long silver
v/ire terminating in a ball at one end and a ring at the other, making it an
exploring instrument, a kind of catheter when straight, and using it as a hook
by bending it, has rendered it easier of managemerit. The crotchet of F,
de Hilden would be much more dangerous; that of Petit, made of a double
flexible wire of silver, twisted and bent in the manner of the palpebral eleva-
tor of Petlier, has nothing against it but its want of firmness. The stylet or
v/halebone rod, carrying a bunch of small movable rings, extolled by the
same practitioner, and which De la Faye modified by merely fixing threads
of flax to the small ring of a stylet of the ordinary catheter, is not to be despised
when the body to be extracted is uneven and of small dimensions. The noose
of packthread or twine, which Mauchart had occasion to praise, the sponge
tied strongly to a thread and carried below the foreign body by means of a
large leaden sound, to the end of which it is fastened, by drawing en the two
ends of the string brought back, one through the canal the other along the
external face of the instrument, as practised by Brouillard ; the same sub-
stance attached to the end of a whalebone rod, as described by Willis,
of an ordinary catheter, or the leaden, or copper sound, perforated with holes,
borro\yed from Arculanus or rather from Ryfl", and modified by Hilden,
who, to render it stronger, added to it a leaden stylet ; the sponge, which
Hevin enclosed in a pouch of lambskin or silk to prevent its dilating before
descending low enough ; which Petit fixed to the end of a slip of whalebone,
enclosed as far as its handle in a flexible sound made of silver wire wrapped
spirally; which Quesney covered with intestine of sheep; which Ollenrotz
suspended to the end of a chain or chaplet composed of sixty-one balls of tin,
may have in every one of tliose ways its particular application ; as also the
kind of brush, mop, or broom, the excutia ventriculi mentioned byWedel,Teich-
meyer and Heister, and which the English, who call it provmdor, form of
small pieces of linen, or a bunch of hog's bristles at the end of a piece of
whalebone, or brass wire. The manner of using these various instruments,
whether for forcing into the stomach or extracting by the mouth the bodies in
question, is too easily understood to require more to be said of it. The same
may be said of their relative value in the different cases in which more than
one of them would be applicable. The skillful surgeon will select the best,
the most simple, the most certain, and the most inoffensive among those
within his reach. The forceps with multiplied branches, which are opened
and closed by a peculiar mechanism before and after seiz.ing the foreign body,
and which M. Missoux described, in 1825, in his thesis under tlie name of
Geranorhynque, although ingenious, is too complicated for adoption. That
just proposed by M. Blondeau, and which is founded on the principle of the
litholabe forceps, enclosed in a flexible sheath, would answer a little better
OPERATIVE SURGERY. 497
if it were not also too complex. The same must be said of the ingenious
apparatus recently invented by M. Parent.
3d. The efforts at vomiting, which many authors have advised us to provoke
(notwithstanding the objections of B. Bell) either by tickling the palate or the
bottom of the fauces, or by gorging the patient with warm water, or in any other
way, form a resource which we should not employ but. for bodies free from
asperities or any projecting points, or after having vainly tried the two kinds of
resource pointed out above, and only then that we may not have to reproach
ourselves with recurring too qui(;kly or without necessity to oesophagotomy.
4th. (Esoplmgotomy. — Although this operation was not formally proposed by
any one before Verduc and Guattani, yet it must be admitted that the idea
may be found in other and older authors. The opening of the abscess con-
taining a small bone which had escaped from the oesophagus, and approached
the integuments of the neck, already practised by Arculanus and Plater ; the
fish bone extracted in the same manner by Houlier and Glandorp; the open-
ing of tumors of more or less density and volume developed on the same
region, by Kerkring, Rivals, &c. naturally led to it. But wounds of the
oesophagus until then had been considered so dangerous that practitioners had
need of numerous facts and direct experiments to dissipate their fears and
their scruples. Since oesophagotomy has taken its station among the regular
operations of surgery, it has received, like almost every other, various degrees
of improvement. Guattani who was not ignorant that the oesophagus is
situated a little more to the left than to the right of the trachea, advises to
make a transverse fold of the skin, and make an incision from the level of the
cricoid cartilage down to the sternum on the left side of the neck, to separate
the lips of the wound with hooks, and arrive by degrees at the oesophagus, and
divide it parallel with its fibres. According to B. Bell the place of incision is
by no means fixed ; for it is proper to make it always upon the projection caused
by the foreign body. He knew, besides, that by'these precautions the recur-
rent nerve would be easily avoided. To be more certain of not opening a
vessel of any size, Richter advises the muscles to be separated by an ivory
knife. The method of Echoldt, praised I know not why by Sprengel, which
consists in making the incision fall upon the triangular space which separates
the roots of the sterno-mastoid muscle, seems to me to deserve the oblivion
into which it has fallen. • Sir Chas. Bell says, that if the thumb be placed on
the course of the internal jugular vein to make it swell during the incision of
the skin, the platisma-myoids, the nervous filaments of the cervical plexus,
and while the other muscles are separated with the handle of the scalpel, the
oesophagus will soon, in some measure, present itself, and in this manner
oesophagotomy is not dangerous ; but' this author is evidently deceived as to
the value of such a precaution. M. Richerand, who admits oesophagoto-
my only in cases where the volume of the foreign body is considerable
enough to make it project beyond the surrounding parts, and who main-
tains with reason that it is almost always at the entrance of the canal of de-
glutition that these bodies lodge, simply adopts the process 'of Guattani or
B. Bell. In this hypothesis, indeed, the external projection is a^ure guide
to the oesophagus, and favors the separation of all the organs which it is impor-
tant to save. An instrument devised by Vacca, allows, in every case, the
same end to be fulfilled. It is a long metallic staff terminating in a knob,
and split in the form of a forceps at one of its extremities. This staff slides
63
498 .NEW ELEMENTS OF
in a canula, which presents laterally an opening several inches above its termi-
nation. The whole instrument is introduced closed until arrived beyond the
foreign body. The surgeon then draws the forceps gently towards him, when
one of its branches, from its own elasticity does not fail to be engaged in the
lateral hole of the sound, which forms its sheath and pushes out on the side
of the neck the several layers to be divided. But the barbed sound invented
by Frere Come for the supra pubic operation is, without doubt, far more con-
venient than the instrument of Vacca, if a conductor is necessary when ceso-
phagotomy is performed. By raising all the soft parts to the left and front
with the beak of a common catheter previously carried down to the body to
be extracted, as proposed by M. Roux, the carotid artery, the jugular
vein, and the pneumo -gastric nerve necessarily remain posteriorly; the
thyroid vessels themselves and the trachea are also sufficiently distant to re-
move all danger from pushing his dart from within outwards, which then is
used as a grooved director, in lithotomy. However, it is unnecessary thus
to grope in the dark. Nothing prevents cutting first, layer by layer, the
several tissues which separate the oesophagus from the integuments, and only
using the sound in the last stage of the operation. In this manner oesophago-
tomy has nothing dreadful nor difficult, and may be performed by every sur-
geon. Strictly speaking there is nothing to prevent the substitution of an
ordinary sound for that of Frere Come.
Manual. — The patient is placed as for tracheotomy, only that his face is
turned a little to the right. Standing at the left, armed with a straight
bistoury, the surgeon divides the integuments and the platysma-myoides to
the extent of two or thi'ee inches upon the anterior edge of the sterno -mastoid
muscle, between the sternum and the larynx, and as directly as possible oppo-
site the foreign body, whose situation he has previously discovered, either with
the blunt staff of M. Dupuytren, the barbed sound, or other instrument; turns
this muscle outwards; displays the omo-hyoid and sterno-hyoid muscles;
divides them in turn ; tears with the beak of a director, or divides carefully
with the bistoury, the fibro-cellular layers which are found a little deeper, as
if for tying the primitive carotid artery ; raises and pushes inwards and for-
wards the thyroid body, continues with the same precautions as far as the
lateral groove between the oesophagus and the trachea; introduces the arrow
sound by the mouth, if he chooses to employ it; makes its tube project
through the oesophagus at the bottom of the wound; fixes it with the
left thumb and index finger ; directs an assistant to push its stylet ; carries
the point of his bistoury on the grooved concavity of this staft", and makes
an incision on the oesophagus proportionate to the size of the body to be
extracted. When the conductor is not employed, the canal is first to be
opened on the side by a small puncture, to permit a conductor to be imme-
diately carried into its interior, and the wound then enlarged with a bistoury
or blunt scissors. If the substance to be removed does not present at the
opening just made, it is to be sought for with forceps or any appropriate
instrument. Tlie wound may be united by the first intention. If an artery
of any size be wounded, it is to be obliterated by a ligature. A gumelastic
oesophagus sound is to be carried through the nostrils or mouth into the
stomach, and is not to be removed before the third or fourth day, in order
that food and drink given to the patient during this time may not prevent
adhesion of the wound, and be infiltrated into the tissues of the sub-hyoid
OPERATIVE SURGERY. 499
region. I learn from M. H. Larrey, that a patient operated on after these
principles at the Val de Grace, was perfectly restored. The anomaly pub-
lished by Steadman, Kirby, Hart, Godman, and Robert, of a carotid or sub-
clavian twining spirally round the oesophagus, or gliding under its spinal
surface to reach the side of the neck, will not cause danger unless the
operation be performed too low down.
CHAPTER II.
The Chest.
SECTION I.
Tumors,
Art, 1. — Extirpation of the Mamma,
Compression, employed from 1809 to 1816 by Yonge, rejected in 1817 as
dangerous by the Middlesex physicians on the report of Charles Bell, intro-
duced again by Pearson, has recently afforded to M. Recamier results worthy
of fixing the attention in the treatment of tumors of the breast. Up to the
month of September, 1829, this practitioner had obtained ten instances of
complete success, four of very decided improvement, and four others of more
moderate encouragement, out of thirty patients whom he treated. In the
greater part of the other cases it rendered removal much more easy and
certain, by reducing the tumor to the smallest possible size, and in some
measure insulating it from the surrounding parts. But this is not a reason
for rejecting the operation, nor as some seem to think for leaving it as a des-
perate remedy for a desperate case. Many women cannot endure compres-
sion, however well applied. Many cases invincibly resist it. Under the
most favorable circumstances, the assiduous attentions which it requires for
months, are of themselves sufficiently wearisome to suggest the question,
whether extirpation ought not to be preferred. It is not, in fact, as an opera-
tion that extirpation of the breast is dangerous, but because it is frequently
followed by a return of the disease. The amount of pain which it causes is
assuredly less than what results from a treatment which must continue from
two to three months. In an instant the patient is rid of the disorder. Fif-
teen days to a month ordinarily suffice for the completion of the cure. On
tlie other hand, there is no reason to believe that the relapse will be less fre-
quent after the use of the bandage than by removal of the scirrhus. Observa-
tion has already proved, that if it become necessary to discontinue the
compression without having entirely resolved the morbid mass, the progress
of the cancer impeded for a moment soon becomes more frightful than before.
To the question whether extirpation is a means which may be reasonably
tried, I do not hesitate to answer in the affirmative. To Celsus who forbids
us to touch cancer because it always returns ; to Avicenna, who never saw
the operation followed by complete success ; to Monro, who proves that only
500 NEW ELEMENTS OF
four women out of more than sixty whom he knew had had no return of
disease at the end of two years ; to M. Boyer, who out of more than a hundred
cases could only cite a very small number of radical cures ; to Rouzet, who
professes to have found in the Annals of Science but equivocal proofs of per-
manent cures, may be opposed the testimony of Hill, who met with but twelve
unsuccessful cases out of eighty-eight extirpations of cancers, for the most
part ulcerated, although all his cases had occurred from two to thirty years
before ; that of B. Bell who confirms the statement of Dr. Hill ; that of Dr.
North, quoted by Dorsey, and who in a hundred cases remarked but a very
small proportion of relapses. MM. Richerand, Roux, Dupuytren, and before
them Sabatier, have on their part had proof that cancer is far from always
returning when extirpation has been performed in time. It is also within my
knowledge that many patients operated upon at Tours by M. Gouraud, at
the hospital St. Louis by M. J. Cloquet, at the hospital of the School of Me-
dicine by MM. Boyer and Roux, or by myself, from two to ten years since,
continue in good health. Cancer of the breast is not an external sign of ge-
neral disease, as maintained by M. Delpech, at least most frequently, except
in an advanced period of its development. In the majority of cases it is
at first but a local affection, but one which continually tends to pervert the
solids and fluids to such a degree as to be reproduced, in some part or other,
although it seemed to be entirely destroyed in the place of its first attack.
Consequently nothing can be more dangerous than to defer its removal under
vain pretexts ; and compression, necessarily less efficacious, is to be proposed
only to pusillanimous patients, or to those who from some other reason will
not submit to the knife. If general or local medications are of any value, the
operation, which is by no means incompatible with their use, can only con-
tribute to their success. It would be wrong to be imposed upon by the
presence of some swellings about the axilla or in the sub-clavicular region.
These tumors may have preceded the scirrhus, or be the effect of it, without
partaking of its nature. Bartholin, Borrich, Assalini, and Desault have seen
them spontaneously disappear after amputation of a cancerous breast. The
same remark has of late been frequently made. This was the case with a
woman, treated in 1825 by M. Roux, at the " Hospice de Perfectionnement,"
who had a row of hardened glands extending from the side of the neck into
the hollow of the axilla. A slight yellowish tint, a commencement of what
is called cancerous cachexia, does not always form an absolute contra-indi-
cation. Having to treat a patient in this condition, Morgagni operated against
the formal advice of Valsalva. The cancer returned at the end of five years.
Morgagni operated again, and the disease was not reproduced. Adhesions of
the tumor to the ribs diminish considerably the chances of success, but do not
render it absolutely impossible. The operation ought, therefore, to be per-
formed whenever the roots of the disease may be extirpated without occa-
sioning too great a loss of substance, and when there is no evidence of its
actual existence in other organs.
History, — That extirpation of the breast still causes so much terror m the
ordinary ranks of society, is to be attributed to the barbarous processes which
have been employed at various periods. Cauterization of the wound, with an
iron moderately hot, mentioned in the writings of Galen ; the precepts of Le-
onidas to burn, at each stroke of the bistoury, the bottom of the incision, to
OPERATIVE SURGERV. 501
prevent hemorrhage ; excision with a knife heated to whiteness, or when the
cancer is adherent, with a blade of horn dipped in aqua fortis, as prescribed
by J. Fabricius, must truly have been accompanied with horrible pains. The
process of Scultetus, which consists in passing two threads crossed through
the tumor to lift it up, cutting it off at a single stroke with a large concave
bistoury, and then cauterizing all the bleeding surface with a plate of red hot
iron ; that of Purmann, who added to these threads a tight ligature on the
the root of the disease for the purpose of benumbing the parts ; those of Nuck,
who used a double hook and falciform knife ; of Dionis, w^ho began by plunging
into the cancerous mass his famous Helvetian forceps, so much spoken of at
the commencement of the last century ; of Hartmann and of Vylhorne, who,
after strangulating the tumor at its base, fixed it with a kind of forceps, after-
wards with the bident of Helvetius, while a mechanical instrument of their
invention performed the excision ; of Schmucker, who after dividing the skin,
pressed the tumor to make it project, passed throiio:h it a kind of awl some-
what bent, and then separated it from the *Jurrounding parts, were also well
calculated to excite similar fears. Those who caused the tumor to drop off
by surrounding it with a ligature dipped, in aqua fortis, or who, after com-
pletely or incompletely excising it in any manner, applied at several times arse-
nic, orpiment, potassa, butter of antimony, &c. ; they who dissected minutely
all the surrounding vessels for the purpose of placing a double ligature around
each, and cuttino; without fear between the two before removino; the cancer,
and who after the incision of the integuments used only their fingers and ter-
minated the operation by extraction, did nothing towards inducing the public
to change their opinion on this subject. At the present time, when removal
of the breast is reduced to its greatest simplicity, there is nothing in it terrible
or really cruel. When the skin is not diseased, and the tumor is neither vo-
luminous nor adherent, the surgeon merely divides the common integuments,
taking care to give the incision all the proper extent, and to have its lips sepa-
rated, while with a hook, or even the ends of the fingers, he draws the scirrhus
outwards, and with the other hand armed with a bistoury destroys all its cel-
lular and vascular connexions. When the patient is of a certain embonpoint,
or when the nipples are naturally very much developed, although the carci-
noma be very much circumscribed and preserves all its mobility, there is some
advantage in not thus saving the skin in cutting out an ellipsis of more or less
extent. The operation is thus rendered easier and more prompt. Its success
will thereby be rendered more probable, for the sides of the wound, being
almost perpendicular, are in better condition to be exactly brought together
than if the whole of the integuments had been preserved. If the skin itself is
included in the disorganization; if it is red and too tliin ever to resume its
primitive character ; if it adheres by its under surface to the morbid mass, we
are obliged to follow the same precept and include all the diseased portion
between two incisions which should always comprise a certain extent of the
sound parts. On the whole, it is better to remove too much than too little,
provided enough is left to close the wound immediately. The circular in-
cision, adopted by many of the ancients, and by Dionis in particular, is es-
sentially defective. It forms a wound extremely difficult to cicatrize, and
the loss of substance which it occasions is much more considerable than in
any other mode of operating. The elliptical incision used by Paulus iEgineta,
502 NEW ELEMENTS OF
and since by Cheselden, &c., is the best of all. The crucial incision, pre-
ferred by Palfjn and Heister, the T incision used by Acrel, and even by Cho-
part, are evidently less advantageous, and are adapted only to particular cases.
Some, with Gahrliep and Sir Ch. Bell, make the great diameter of this in-
cision vertical ; others, with Desault, transvere, while the precept of Pim-
pernelle, laid down by Verduc, which consists in directing it obliquely from
above downwards, and from without inwards, that is, in the direction of the
fibres of the pectoralis major, is generally followed by the moderns.
The advantage of being better able to apply the means of union in the first
case, is more than compensated by the risk of cutting perpendicularly tlie
muscular fibres, and of finding difficulty in bringing outwards the sternal
portion of the integuments. The second process is liable to the same incon-
veniences without offering the same advantages. Consequently the oblique
incision, which permits as well as any other, the use of the strips, and
which leaves untouched the facia of the pectoralis major, or at least divides
it only in its longitudinal direction, deserves the preference which is now
generally given to it. Strictly speaking, any cutting instruments will serve
for this operation; a razor or amputating knife would do in case of necessity.
The bistoury, with a broad square point, invented by M. Dubois for the
purpose of more certainly avoiding the chest, is not of more or less value than
any other. The common straight bistoury, or better, the convex bistoury, is
what is commonly used. To prevent the blood which flows from the first
incision from impeding the execution of the second, surgeons begin, as.
directed by Palfyn and Desault, with the inferior. Yet there is an advantage
after division of the integuments, in dissecting the tumor from above down-
wards. In the other direction, the inferior or external edge of the pectoralis
major would be much more exposed t6 the knife. For the rest, no one now
regards the advice of Home, Lapeyronie, and Le Dran, to begin with a
crescentic incision, and not complete the ellipse which the wound is to represent
until after having detached the cancer, proceeding all the time in the same
direction, and then to cut through the skin from within outwards. This
mode, however, has no other defect than of rendering the end of the ope-
ration a little less regular, and being likely to remove too much or too little of
the cutaneous covering. When the loss of substance is considerable, so as^
to render the coaptation of the division impossible, or at least very difficult,
M. Lisfranc proposes to insulate each margin of the wound from the parts
beneath for one or more inches, in the hope of thus removing every obstacle
to their approximation. This is a modification, the full value of which I
believe has not been felt till now. By this means enough skin is always
found to cover immediately the solution of continuity. The integuments are
then borrowed from the surrounding parts as in the cheiloplasmus, and this
must be a valuable resource when it is necessary to remove a great portion of
the tegumentary envelope. The arterial branches which are divided belong
to the external inammary, the superior thoracic, the internal mammary, or
the intercostal arteries. It is always towards the outer side that the largest
are founds which are first to be attended to. By casting a ligature about
them as soon as they are opened there is no fear of their retracting and being
lost in the tissues, nor that the action of the air will prevent their being found
afterwards ; but the operation becomes thereby much more tedious and pro-
OPERATIVE SURGERY. 503
longed. If they are not too numerous nor very large, I prefer that an
assistant should close them with his fingers as soon as divided. If after
cleansing the wound some remain which cannot be found they are commonly
too small to cause any uneasiness. Moreover, in the opposite case it would
be easy to establish mediate or immediate compression over them, so that
on this point there is really little cause for apprehension. When the wound
is to be healed by the first* intention, ligatures are not always indispensable.
Theden never applied them. Petit and Le Dran usually dispensed with them.
D'Arce and Vanhorne, who also omitted them, extracted the tumor with the
fingers, and only used the bistoury for dividing the integuments. I dispensed
wiSi them upon a strong and plethoric young woman from whom I had just
removed a scirrhous mass as large as the fist. Prudence, however, requires
that all that can be seen should be tied or twisted, and that if any escape the
eye of the surgeon, the dressings should be watched attentively for a day
or two. The precaution of not definitively dressing the wound until after
several hours, so as to give time for the eccentric action of the vascular
system to be re-established, and thus discover the arterial mouths which it is
necessary to close, has the serious disadvantage of annoying the patient
greatly, and to say the least, of being unnecessary. At present it would be
ridiculous and cruel to dissect, as has been advised, and excise afterwards all
the veins which go to the breast, or merely to squeeze them with the fingers to
drive out the black or atrabiliary humor, so much dreaded by the ancients.
Immediate union, advised by Paul and Gahrliep, praised by Nannoni, who
confined himself to bringing the lips of the wound together ; by Cheselden
and Garengeot, who used the suture, and which almost all modems have
adopted, has nevertheless still some opponents. It is correctly accused of
preventing the escape of matter if it form at the bottom of the wound ; of being
frequently followed by phlegmonous erysipelas, and therefore of endangering
in a high degree the success of the operation. These accidents, formidable
especially to such women as are large or cacochymic, would be most frequently
avoided if no vacancy were left at the bottom of the wound, if coaptation
Were more exact near the muscles than towards the skin, if the strips should
act principally on the deep parts, and not on the skin alone, and if care were
taken to preserve an issue at the most depending point for the passage of the
fluids. For the rest as it is almost impossible to obtain completely immediate
union (I succeeded once, upon a man ; I had but one artery to twist and the
scirrhus did not exceed a small egg in size), perhaps it would be wiser to treat
the wound by what may be called secondary immediate union. The cure would
not be sensibly retarded, and the patient would have none of these dangers to
encounter. As to the suture, although earnestly recommended anew by M.
Serre, I cannot dare to advise its use in this place until having seen more
fortunate and conclusive results than those yet furnished. It evidently ren-
ders the operation more painful, and except some cases in which the skin
being thin and dissected up tends to roll upon itself, strips or the simple
bandage will fully serve the purpose. Since without it a difinitive cure
may take place in from ten to twenty days, I cannot see in what consist it»
advantages.
ManuaL — Although, according to the custom of many practitioners, the
patient may be seated in a chair during the operation, there are, neverthe-
less, incontestable advantages in a recumbent position on a bed or operating
504
NEW ELEMENTS OF
table. Syncopes are then less to be apprehended, and in reality the surgeon
is more at his ease. The head and chest are kept sufficiently elevated to
render the breast as prominent as possible. The cushion which Bidloo placed
in the axilla to push the gland forwards while the arm is drawn backwards
would not deserve mention, if Mr. S. Cooper had not advised a precaution
somewhat similar and no less strange ; he directs, in order to keep the arm
from the body, to govern the motions of the patient and to stretch the pecto-
ralis major, that a stick be placed in the axillary hollow on each side between
the body and the arm ! An assistant raises the tumor with one hand, and
with the other sponges the wound. The surgeon drawing the skin in the oppo-
site direction, begins with the inferior semi-lunar incision, depresses the
mass to be removed, causes the integuments to be stretched from above;
and performs the superior incision, beginning at the external angle of
the first wound and carrying it to its other extremity, and thus com-
pletes his ellipsis; takes hold of the scirrhus or directs it to be done,
dissects it largely first from below upwards, then from above downwards, and
so conducts the operation that the diseased gland shall be surrounded with
sound tissues, and not be removed alone ; goes, or should not fear to go^ as
deep as the fleshy fibres, and even to the osseous arches of the breast if the
disease extend so deeply. If he does not tie the arteries, as I prefer at least
when they are not too large, he orders them to be pressed with the finger as they
are divided by the bistoury, and may thus finish in a few seconds the extirpation
of the largest breast. If some morbid portions escape the instrument at first
they should be removed afterwards without hesitation. When belonging to
the soft parts they are brought away by the knife or scissors. If the bones
be affected a rugine may be necessary. Having gone thus far we should not
shrink from removing one or more portions of the ribs, if their excision appear
to destroy all the disease; but if, before commencing, this necessity be indi-
cated by any sign, it will be better, in my opinion, not to attempt the operation.
If any tumors exist in the axilla, which create apprehension, they are to be
laid bare when not too distant, by prolonging thus far the external angle of
the wound. In the contrary case it is better to dissect them out by separate ^
incisions. Their situation although capable of exciting fear at first sight "
permits their extirpation in almost every case without the least danger. They
are in fact almost constantly found on the external face of the serratus magnus,
so that to keep out of the way the brachial plexus, it is sufficient to raise the
arm and hold it from the body. Nothing is easier, therefore, when the wounding
of any large vessels is dreaded, than to pass a ligature round the pedicle,
after properly insulating them, and then cut them without the knot. This
practice, which is advised by J. L. Petit and Desault, and adopted by Zang,
Dupuytren, and Lisfranc, ought to be retained. As to opening the veins, it
is rarely troublesome with regard to hemorrhage. I have seen M. Roux wound
the axillary vein itself in this operation, and plugging was enough for any
return of the effusion of blood. Having cleansed the wound and surrounding
parts, if immediate union is to be attempted, the operator gently approximates
the sides of the disunion, and preserves them carefully in contact with the
thumb and index finger of each hand, while an assistant applies the adhesive
strips. In general, the longer the strips the better. When spread over a
large surface their action is less felt towards the division of the skin, and
keep in place much better than if short and more numerous Some persons
OPERATIVE SURGERY. 505
of great merit, however, maintain the contrary; and professor A. H. Stevens,
of New York, among others directs tliem to be as short as possible. They
should cross the wound at riglit angles. When the loss of substance is con-
siderable, or when the integuments are with difficulty brought in coaptation,
there is an advantage in fixing them behind the sound shoulder, and bringing
them over the clavicle, carrying them belov/ the axilla towards the flank of
the diseased side ; the middle one is first applied, and those of the ends the
iast. Their number must necessarily vary according to the extent of the
wound, over which they should form n'^grillage quite close, whenever a
primitive adhesion is desired, otherwise it is but to leave considerable spaces
between them, that the pus or other fluids, if any be produced, may not be
retained. A pledget of lint spread with cerate, one or two dossils of dry
charpie supported by a body bandage, or circular turns of a long bandage
passed once or twice around the shoulders, complete the apparatus, and the
patient may be immediately put to bed. When immediate union is impracti-
cable or is not desired, the plaster strips are usually unnecessary. The wound
is covered with strips of linen spread with cerate, or a fine cloth oiled and
pierced with holes, so that the charpie which is placed above may be easily
removed from the first dressing. If, afterwards, the least vegetation or
tubercle of a doubtful nature manifest itself, its destruction should be effected
without hesitation, and as promptly as possible, either with the knife, fire,
arsenical paste or other caustic, as advised by De la Poterie, F. Come, Dubois,
Patrix, &c. Cancers which admit the least hope on this subject, belong to
the cerebriform, melanare, and scirrhous tissues. Those which seem, and
really do extend into the surrounding cellular tissue by a number of diverging
xatiii or roots, are the most formidable of all, and rarely fail to return ; while
the extirpation of colloid, hydatiform, encysted and tuberculous cancers, are,
on the contrary, most frequently followed by a radical cure.
«5r/. 2. — Extirpation of Tumors of the Axilla.
Masses, cancerous or not, may be developed in the axilla without disease of
the breast, as well in man as in woman, and there acquire an enormous size,
so as to be destroyed only by extirpation. I have published several remark-
able cases, and M. Goyraux, has just related another not less so. Whenever
they may be removed entire by the base, it should be done as in extirpation
of lupi in general. If the clavicle has been raised up and the pectoral muscles
extenuated by one of these tumors, it is to be attacked on its anterior face as
was done by myself in the case of a young woman twenty-four years old, at
the hospital of Improvement in 1828. One of the branches of a crucial
incision, directed from the internal third of the clavicle, to the posterior edge
of the axilla divided the whole thickness of the pectoralis major and minor
muscles. I was obliged to dissect the whole brachial plexus, and to lay bare
the principal artery to the extent of two inches, to follow even into the sub-
clavicular hollow, and insulate, as well with the fingers as with the bistoury,
the morbid production, which in size equalled at least the size of the head of
a new-born child. For those which have acquired less volume and retain
their mobility, we are to act in the manner just laid down for scirrhus of the
mamella, complicated with swellings of the axilla. What I have advanced in
64
506 NEW ELEMENTS OF
regard to the dangers of the introduction of air into the circulatory passages
and wounds of the veins, in speaking of extirpation of the goitre, being equally
applicable here it is not necessary to revert to it.
SECTION II.
Effusions.
»Brt, 1. — Ejnpyema.
Practised since the highest antiquity, the operation for empyema owes its
origin, according to fabulous history, to the despair of a certain Phales or
Jason, who, seeking death in the midst of battle, received a lance wound in
the breast, and was thus cured of an empyema of which no one would under-
take the cure. Galen asserts that it was performed in Greece by plunging
a red hot iron into the thorax. After being assured of the existence of the
collection, at the time of Hippocrates, one of the last intercostal spaces was
opened with the bistoury or a lancet wrapped with linen to within a certain
distance of the point. For fear of evacuating too quickly all the morbid matter,
others perforated the fourth rib with a trepan, and then closed the opening
with a plug or tent. The Arabians seem to have acted on this point in the
saifte manner as the Greeks and Romans. With all, we find that the ope-
ration for empyema, which was at first recommended and employed without
repugnance by most practitioners, in the end was recommended by none.
Paulus Egineta, among the first, directs in its place cauterization of the thorax,
and Aly Abbas, among the second, formally rejects it. G.de Salicet and Guy
de Chauliac, mention it with extreme timidity. A Benedetti, I. de Vigo, and A.
Pare, succeeded in raising it but for a moment from the discredit into which it had
fallen, and it required no less than all the efforts of J. Fabricius to bring it
again into repute; so that in reality, it is only since the last two centuries that
its advantages and disadvantages have been discussed, and that it has again
fixed the attention of surgeons. At present it is rarely used, perhaps too
rarely; and it is yet to be demonstrated, whether the kind of anathema which
the moderns have hurled against it be legitimate and just in all its points.
Sanguineous Effusion, — Whether the blood which accumulates in the
pleurae be given out by the intercostal arteries or the deep vessels, whether
it come from a traumatic lesion, a penetrating wound of the chest, or a
spontaneous rupture, whether it be arterial or venous, the dangers which,
result, and the assistance to be rendered, are in all cases nearly the same.
The advice of the ancients, who direct the immediate removal of the ex-
travasated fluid, either by placing the patient on the wounded side, or by
enlarging the wound, or by using the mouth, a cupping glass, or syringe, to
pump it out — an advice generally followed even until of late — far from being
advantageous, appears on the contrary to be extremely objectionable. The
injured vessels cannot be obliterated and closed, except under the influence
of coagula more or less solid, and of some compression. If, instead of being
retained within the chest, the blood escape, this compression will not be
established by coagula, and the hemorrhage will only end in death. Reason
therefore prompts to close immediately the wounds of the chest instead of
OPERATIVE SURGERY. 507
dilating them ; to imprison in the interior the extravasated fluid, instead of
procuring it an issue. If the extravasation is inconsidei'kble, absorption will
most commonly remove it; in the contrary case its source can only be stopped
by its own presence — :by the mechanical reaction which it exerts upon the
wounded organs ; so that the operation for empyema belongs in no manner
to recent traumatic hemorrhages of the thorax. Some facts collected from
the time of Vigo and Pare, a passage of Francois d'Arce, another of G. Horst,
the words of Sharp, and especially of Valentine, ought to have pointed out the
way to this truth ; but it was reserved for A. Petit, and M. Larrey to
demonstrate it and gain the admission as a principle by all modern surgeons,
that the first indication in penetrating wounds of the chest, with or without
extravasation, is to close them immediately. If in the end the organism,
aided by a well directed general treatment, continues unable to remove the
morbid collection; if when the wounded vessels have had time to become
obliterated this collection threatens of itself serious accidents, it is then
proper, but only then, to have recourse to the operation, and to make what is
called a counter-opening.
Effusions of Pus. — As purulent collections in the chest are far from being
always the principal disease, the operation for empyema is, in its turn, far
from being always of great assistance in the case. If the cause is ascertained
to be a tuberculous vomica or any other incurable lesion of the pulmonary
organ, or an extensive alteration still existing of the heart or pleurss, the
opening of an issue only hastens the end of the patient. If, on the contrary,
the collection is the consequence of a simple phlegmasia, a pleurisy for
example; an abscess in the lungs opening into the pleura — in a word, if after
removing the pus, we can hope to stop its source, the operation offers some
chance of success and oug-ht to be tried, if nothino; in the general condition of
the patient contra-indicate it. A peasant from the neighborhood of Tours,
operated on under these circumstances, in 1814, by M. Gouraud, was per-
fectly restored. In the cases to which it applies, the extravasation approaches
the nature of an external abscess. The organism has, most frequently, taken
care to surround it with adhesions which more or less circumscribe its limits ;
so that, after the opening is made, there is nothing to fear from contact of the
air with the rest of the pleura. In proportion as it is emptied, its parietes can
gradually close upon themselves, and soon entirely obliterate it. The same
remark may be applied to sanguineous effusions, which in the end are almost
always crowded into a space more or less contracted, under the influence of
adhesive inflammation of the surrounding surfaces.
Serous Effusions. — Serum does not give the same chances of success. The
surfaces which furnish it are not sufficiently irritated, at least generally, to
contract mutual adhesion. The lungs somewhat compressed towards its root,
is then incapable of resuming its natural dimensions; and the chest, once
opened, brings the whole extent of the pleura in contact with the atmosphere,
so that in such a case many experienced surgeons inject even the idea of an
operation. However, if all the means which reason and experience indicate
have been tried in vain, if it is not certain that an incurable organic lesion is
the cause of the extravasation, and if alarming symptoms such as those of suf-
focation threaten the life of the patient, the operation for empyema is a last
resort, which it would be inhuman not to attempt. M. Gouraud, who ably
508 NEW ELEMENTS OF
defends this hypothesis, obtained by it a remarkable success in 1808, and in
scientific compilations are found here and there some other examples. The
artificial subtraction of a part of the extravasated fluid excites in such a
degree absorption in the pectoral cavity, that a number of practitioners have
thought it should become a precept that the operation for empyema should follow
pleurisies when resolution cannot be expected. The patient mentioned by
M. Martin Solon, who is one of its declared partisans, died. The same was
the case with a patient operated on in 1830, at La Charite, and with another
whose thorax was opened at the hospital St. Antoine, during my period of
service.
Effusions of Gas, — The presence of air or gas in the interior of the pleurae,
which so many physicians have found there since M.Ttard made it the sub-
ject of an interesting work, whether owing to the rupture of a pulmonary
cell, to the decomposition of certain liquids, or to a pure and simple exha-
lation, is however one of the circumstances which may in strictness require
perforation of the thorax. Riolan and H. Bass have had proof of it in patients
whose chests, instead of pus which they expected to find, contained in reality
only air. The researches of A. Monro, of Gooch, and particularly of Hew-
son, leave not the least doubt on the subject. But it must not be forgotten
that it is a symptom not serious of itself, and capable of spontaneously dis-
appearing, and that if it is coincident with profound organic alteration, the
operation for empyema will only have a momentary triumph. Although a
mere palliative in the majority of cases, perforation of the thorax will yet
sometimes effect a complete cure. If formerly it was frequently performed
without necessity, it appears to me that at present we have fallen into the
opposite fault, in too generally proscribing its use.
Operation, — The dangers that attend it are easy to be conceived. If the
lung, a long time compressed, has not lost its natural permeability, the air
rushes in with force immediately after the substraction of the effused fluid,
and may thus become the cause of irritation or violent inflammation. Sup-
posing this organ to be so compressed as to yield only gently to the
mechanical action of the atmosphere, the kind of vacuum which is formed
immediately around parts which have been exactly sustained until then,
necessarily disturbs pectoral circulation and respiration. Without being
injurious or irritating of itself, as many authors still admit, yet the air most
commonly exerts a dangerous influence over the sequelse of the disease.
Introduced into the chest through an opening generally very small, it becomes
warm and mingles with the morbid deposite which covers or bathes the pleura,
combines by mutual decomposition with the remaining effused fluid, which
quickly assumes an acrid and putrid character which is foreign to it, the
action of which is but ill borne by the organism. It is this new substance
and not the air which inflames the environs of the disease, and produces gene-
ral reaction, sometimes very intense and too frequently fatal ; it is this also,
which penetrating in greater or less proportion into the mass of circulating
fluids, infects them and gives rise to those adynamic phenomena, of which a
number of unfortunate patients thus treated are the victims. The danger
will then be in proportion to the extent of the parietes of the collection, the
degree of exhaustion, irritability, strength, and vital resistance of the patient,
and also influenced by the nature of the effused fluids, and the condition of
OPERATIVE SURGERY. 509
the thoracic organs. Three points deserve the attention of the surgeon in the
operation for empyema; 1st, the place in the chest where it should be per-
formed ; 2d, the instrument most proper for its performance ; and Sdly, the
requisite dressing.
Place of Election.-^When the eifusionis not circumscribed by any adhe-
sions, and the pleurae are entirely free, it is advised to open the pectoral cavity
at the point most depending and most favorable to the issue of the fluids, and
this point is called the place of election. When the collection occupies only
one portion of the chest, and is so limited that neither the position nor the
movements of the patient can make it change its place, the opening must be
made on a determined point, and this is called the place of necessity. This
has never varied, and cannot according to the whim of practitioners. The
other, on the contrary, being an affair of choice, could not be expected to be,
and in reality has not been, the same with all surgeons. Some, with F. Wal-
ther for instance, have fixed it in the fourth intercostal space, counting from
above downwards ; others in the fifth, with Leonidas and Fabricius d' Aqua-
pendente ; others in the sixth, with Sharp, B. Bell, &c. ; and Heers directs it
to be in the seventh. There are some, who like G. de Salicet and Lanfranc
prefer the eighth ; others, with A. Pare, the ninth. Solingen thinks that the
tenth, directed by A. Lusitanus, for the left side, and the ninth for the right,
are best ; in fine, Vesalius and Werner say that the eleventh offers the most
advantages.
At present the general preference is given, in France at least, to the third
on the left, and the fourth on the right. Lower down, the diaphragm and the
liver may be wounded, and the instrument may be carried into the peritoneum
and strike below the collection ; higher, we would miss the most depending
point, and the liquid will not flow with the desirable facility. To these rea-
sons, it is true, it may be objected ; first, that in abundant collections the dia-
phragm, and the liver with it, are too powerfully forced downwards to be
injured even when we penetrate between the second and third rib, secondly
that we may change at pleasure the depending point of the thorax by the
position given to the patient, and that in this point of view, the sixth or the
ninth intercostal space is nearly as advantageous as the third ; but as there
is no disadvantage in following the precept established amongst us, it may as
well be conformed to as another, and the more so as the feelino: of suffocation
which habitually torments patients affected with effusion into the thorax, ren-
ders it difiicult for them to use any other than a sitting Or nearly vertical
posture. I do not see, however, why we should be confined too rigorously to
strike rather above the third than the fourth rib when tliere is any difficulty
in distinguishing them. The intercostal space being once determined, it
remains to decide on what point of its length the operation is to be performed.
Neai' the sternum the internal mammary may be wounded ; more externally
are found the descending and anastomosing branches of this artery. On the
side of the spine is the mass of the sacro-lumbalis and longissimus dorsi; a
little further on the side of the trunk tlie intercostal artery being as yet
uncovered, and unprotected by the inferior edge of the rib, may be easily
opened. It is therefore with reason that the point of union of the posterior
third with the anterior two thirds of the pectoral boundary has been selected.
There the opening falls in front of the latissimus dorsi, between tlie faciae or
510 NEW ELEMENTS OF
digitation of the serratus magnus and the obliqus externus. There are
only the integuments, the intercostal muscles, and the pleura, to be divided.
The artery lodged in the costal groove, is not yet bifurcated, and the space is
sufficiently large to admit the end of the linger. However if this point did
not offer the very great advantage of being the most depending, when the
patient is gently inclined to one side, sitting, or lying, there would be little
disadvantage in going more behind or to the front, as David and some other
practitioners have recommended. Many means have been proposed to deter-
mine exactly the position of the third intercostal space. If the patient is
lean and not anasarcous, the ribs may be counted from above downwards, but
when oedema or a thick layer of cellular or adipose tissue covers the bars of
the thorax, we are obliged to act otherwise. According to some, when the
hand of the patient is applied in front of the sternum, and the arm hanging
along the side of the trunk, the elbow pushed a little back corresponds exactly
to the space sought for. This mode of exploration, besides being very
incorrect, is more proper to designate the space between the last two ribs than
between the ninth and tenth, and that which consists in penetrating into the
chest at six fingers' breadth below the inferior angle of the scapula, would be
much more certain and rational if such a determination had really the im-
portance formerly bestowed upon it.
Formerly it was an affair of great moment to mark the place of necessity in
the operation for empyema. If no tumor be manifest, or no external indica-
tion ; if the use of a cataplasm, which should dry up quickly according to
some, on the contrary remain humid according to others, opposite the effu-
sion, indicate nothing, it will be necessary to refer to the feelings expressed
by the patient, to succussion, or perhaps to means still more fallacious. But
the labors of Avenbrugger, of Corvisart, of Laennec, and of M. Piorry have
happily removed this uncertainty; so that at present it is almost as easy to
detect the precise seat and limits of disease in the interior of the chest as if
they were on the surface of the body.
Instruments. — To guard against hemorrhage, or to obtain a wound with loss
of substance, or because they attributed some particular virtues to escharotics,
the ancients and several authors of the middle ages frequently employed
caustics, chemical or metallic, for opening the chest. The contemporaries of
Leonidas employed a cautery in the shape of a fruit stone. Cinesius, men
tioned by Galen, also used the red hot iron. That of Rhazes was fine and
pointed. Albucasis used one of a triangular form. A. Pare directed it to be
furnished with a concave plate at some distance from its point. But this
method, long since abandoned by the moderns, would scarcely deserve men-
tion if it had not been extolled by M. Gouraud, who applied it particularly
to collections of pus, and who attributes to hot iron the advantage of permit-
ting the abscess to empty itself after the eschar comes away; and to the
wound that of opposing the entrance of air, by the swelling of its edges. The
scolopomachairion of Paulus Egineta, the phlebotome of the Arabians, and
the sagitella of Arculanus, which were formerly used, have disappeared from
practice. The common bistoury and the trocar now supersede all other
instruments in tapping the chest. Although Pare proposed the punch for
paracentesis, in order to perforate a rib in preference to an intercostal space,
yet it has only been since Drouin and Nuck that attention has been really
./
OPERATIVE SURGERY. 511
directed to this point. Dionis, Heister, and particularly Morand, have
pleaded the cause of the trocar, which still reckons many partisans, and has
the advantage of rendering the operation easy, prompt, and but little painful,
and the entrance of air almost impossible ; of not forcing the collection to be
emptied at once, and in fine, of allowing a great number of punctures in cases in
which they may be deemed necessary. But as its canula has the disadvantage
of not always giving free issue to matters of some consistence, such as grumous
pus and blood partly coagulated, it is far from suiting every case indiscrimi-
nately. Thus it is not generally preferred except in hydrothorax, and exten-
sive pleuritic effusions. But there is nothing to prevent a small puncture
from being transformed into a large wound immediately, if the liquid does
not flow readily at first; and I cannot see why the lung or the diaphragm runs
more risk of being wounded with this instrument than with any other.
Paracentesis of the chest is in other respects governed by the same rules as
paracentesis abdominis, of which we shall treat hereafter.
If the intention of the operation is to remedy an efiusion of air, the wound
generally requires no treatment. In the other cases the manner of proceeding
is not so clearly laid down. In truth, the pyulcon of Galen, cupping glasses,
syringes, and suction so much lauded in the sixteenth and seventeenth cen-
tury, for the removal of the very last particle of the effused fluid; the
various species of canulae for a long time used, and twice by Hey to prevent
the pleura from collapsing too soon, and for emptying the chest by degrees,
have long since lost nearly all their reputation^ although practitioners still
deliberate whether or not it is right to evacuate at once the seat of the morbid
collection, to keep in it a foreign body to act as a filter, and make injections
rather than heal the orifice immediately. Unless the lung enjoy all its
expansibility, which is very rare in hydrothorax, there is undoubtedly an
advantage in letting the serosity escape but little at a time, and in introducing
a strip of linen or a tent of charpie into the cavity of the pleura, so that at
each dressing a new flow may be produced. When the case is an empyema,
properly so called, or is an effusion of blood, this tent ought not to be neglected
if any importance is attached to the non-admission of air into the cavity. In
other respects, the rule of conduct is the same as in paracentesis with the
trocar. The employment of injections demands all the solicitude of the sur-
geon. It is the abuse of them by the ancients that has induced the moderns
almost generally to proscribe them. They are improper in hydrothorax and
in effusions which are not bounded by any adhesion. In oilier cases, on the
contrary, their advantages cannot be contested. As soon as the suppuration
tends to become corrupted, they alone are capable of preventing adynamia
and decomposition of the fluids, by cleansing the morbid surface and bringing
out the altered matters as they are formed. It is therefore evident, that the
precaution of raising the skin while perforating the intercostal space, in order
to bring at different heights to the opening of the pleura, and that of the inte-
guments, is hardly necessary, and far from deserving the importance generally
bestowed upon it since Bass elevated it into a precept.
Manual. — A convex bistoury, a straight bistoury or a trocar, a vessel to
receive the fluid, a strip of scraped linen a yard long and of the breadth of the
finger, several pledgets of charpie, compresses, and a body bandage, together
with a gum elastic canula and a syringe, are all the objects necessary. ^ Seated
512 NEW ELEMENTS OF
on his bed, rather than on a sofa or chair, and inclining more or less to the
right side, the patient is kept in this position bj assistants, so that the inter-
costal space to be opened may be stretched as much as possible and quite free.
Placed in front and somewhat to the right, the surgeon stretches tlie skin with
his left hand, and with a bistoury in his right divides it parallel witli the
superior edge of the lower rib, from left to right for the right side, but in the
contrary direction for the left; cuts in the same direction^ successively layer
by layer, the adipose tissue, a thin laminse'of cellular substance, the external
muscles of the chest, if any exist at the point selected, and the external and
internal intercostal muscles; having arrived at the pleura, and in order to
pierce it without fear of wounding any other organ, uses only the point of tlie
bistoury, resting with its back on the end of the left index finger which serves
it as a guide ; gives to the internal opening an extent of from six lines to an
inch, and thus penetrates into the interior of the cavity whence the fluid is seen
immediately to flow. If, as is frequently observed, some factitious laminas
are attached to the internal surface of the pleura, there is so much the less
reason for stopping at this difficulty, as we may in strictness penetrate ever
the substance of the lung itself if the seat of abscess be there. The point
is not to miss the morbid sac. Nevertheless, in the case where this point may
have been overlooked, unless the matter be within a distance which permits
us to feel its fluctuation with the finger, it would be much better to make a
second opening in the proper place than to break down the surrounding adhe-
sions, either with the finger, the handle of a knife, or a probe, or especially
with a bladder carried empty through the wound, and then filled with air or
liquid while in the thorax, which was recommended by some old writers.
Process of the Author. — The motives on which is founded the perforation
of the wall of the thorax with so much preparation, seem to me unworthy the
sanction they have received. What is to be feared from penetrating by a
single thrust into the pleura .^ To touch the lung. But this accident is not
possible except in case the instrument deviates from the direction of the dis-
ease. Besides, the lung is free and sound behind the wound, and then the
pleura is no sooner opened, than the pressure of the atmosphere forces it
towards the spine, unless intimate adhesions unite it to the thoracic parieties,
and in this case what danger can result from a small puncture of its paren-
chyma ? I think, therefore, that the operation for empyema would be infinitely
more simple,- and equally as certain, if in performing it we were to pass
through suddenly, and without hesitation, the intercostal space with the bis-
toury held in the second or third position, that is as in external abscesses
which are opened from within outwards. In this manner will be united in
some degree the advantages of paracentesis with those of incision, and the
opening of the chest, which at first sight appears so formidable, will in reality
scarcely deserve the title of an operation.
liemarks.-^l designedly omit the precept of those who direct before in-
cision of the integuments to make a large perpendicular fold of them over the
ribs, instead of stretching them with the hand, andof others who have thought
the incision of the skin should be perpendicular and not horizontal. It is
sufficient to mention such counsels that every one may estimate tliem at their
proper value. I will say still less of the method of Mercati, which consistecl
iu penetrating only to the pleura M'ithout touching it, that the fluid itself
OPERATIVE 5URGEKY. 5 IS
might cotnplete the perforation. It would be equally puerile to finish the opera-
tion with the lancet after using a bistoury for commencing it. The intention is,
to arrive surely and without danger within the pathological limits. Nothing
can present less difficulty, and this is certainly not the reason why the operation
for empyema should appear so formidable. An effusion, considerable enough to
require surgical aid, would destroy the patient if it existed on both sides at
once before we could think of the operation. On a contrary supposition we
must follow the advice given formerly by A. Benedetti, to open the two la-
minae of the pleura, with an interval of several days, and to take all necessarj
precaution to prevent collapse, and shrinking of the lungs. If the operator
does not wish the wound to remain open, he brings its lips together when
there is nothing more to be extracted from the seat of disease ; keeps them
In contact by a strip of diachylon ; covers it then with charpie; afterwards a
compress ; and fixes the whole with a body- bandage moderately tight. If he
has not removed the whole of the matter, a flat dressing with charpie spread
with cerate is ordinarily sufficient to obviate the too speedy adhesion of the
edges of the perforation. To be more at ease on this point, however, there is
nothing to prevent the insertion in the solution of continuity with the poHe-
meche, of a little cone of charpie, or one of the extremities of the linen band
prepared for this purpose ; for the rest every thing is conducted as above.
The tents, which were formerly employed for the same end, and which vvcre
fastened without by means of a thread, besides the inconvenience of formin<j;
a stopper, were also liable to escape into the morbid cavity and be there lost,
an example of which is given by Guy. As long as the fluids which are dis-
charged at each dressing preserve their primitive character, and do not
deteriorate, injections will only be injurious. On the contrary, we should
iiave recourse to them when the least change is manifest. In this respect,
v/arm water, at first honied barley water, weak lime water, then lead water, or a
weak decoction of kino, are to be successively or alternately tried, as well as any
other detersive, astringent, or antiseptic fluids, which the practitioner may
choose according to the indications. M. Bache affirms that this method, long
since adopted in the hospital of Grenoble by M. Billery, who besides was in the
habit of closing the wound with a plug of gentian in the interval of the dressings^
was often followed with complete success. The apparatus lately devised by M*
G. Pelletan, which by means of canulas and valves, permits the establishment of
a double current of liquid by opposing the introduction of air into the thorax,
an apparatus in other respects founded on that of M. Heroldt, is too compli-
cated and of too little necessity for practitioners to consent to its use.
Art. 2. — Wound of the Intercostal Artery.
Supposing a wound of the diaphragm, of which Solingen says he was
witness, should occur during the operation for empyema, there is no resource
but that of medicine to be summoned against it, and the opening of the inter-
costal artery is in fact the only accident which can here require surgical aid.
Although rare, this wound has occupied the attention of writers, so that a
greater number of means have been proposed to overcome its effects than the
times it has been observed ; unless perhaps it has been frequently mistaken,
or the remedy has been neglected even in cases in which the resulting effusion
has become fatal, an example of which M. Thierry published in 1828. It
65
514 NEW ELEMENTS OF
has mostly occurred in consequence of penetrating wounds of the chest. It
is recognized by the hemorrhage it occasions, by the symptoms of effusion
which result, by the pallor, and threatened syncope, &c. A piece of card
carried to the bottom of the wound and bent into a gutter shows on what
side the blood escapes. The finger passed under the rib often distinguishes
a hot jet not easy to mistake, and forms one of the most certain means of
diagnosis when it can be employed. By means of a thread carried through
the wound, and brought out through the intercostal space above, Gerard
conducted a tent beneath the artery which he hoped thus to compress by
strangulating it with the rib. Not willing to withdraw the conducting instru-
ment entirely through the new wound, Goulard invented a needle with a
curved handle, like that of Gerard, pierced with an eye near its point, and
hollowed on its convexity into a groove for carrying the ligature. Heuermann
contends, that with a needle considerably bent and fixed at an angle with its
handle, it is possible to surround the bone so as to bring out the two extremities
of the thread at the same wound. Having made a second opening above the
rib, Leber used it to carry a tape which he brought out of the wound, and then
tied its two ends over a conpress, in the manner of Gerard. For this purpose
he employed a flat flexible sound, for which Steidle substituted a silver one
bent into the shape of an S, to which, in his turn, says Sprengel, Bostscher
preferred a blunt probe-pointed one of steel. In fine, instead of tying the
thread into a knot, Reich advises to pass its two extremities into a gumelastic
canula which is kept without the chest; but all these processes are unnecessary,
as well as the double plate of Lottery, the ivory counter of Quesnay, and the
machine of Bellocq. The tent, tied round its middle by a very strong thread,
carried through into the cavity of the pleura, and then placed vertically, so
that by drawing on it it cannot be brought away, compresses the artery, and at
the same time the edges of the two adjoining ribs no longer receives the
eulogies lavished on it by Bilguer, Richter, Desault and Sabatier. Theden
maintains, that to arrest the hemorrhage it is sufficent to complete the
division of the artery, bend back its posterior end, and plug the wound. I add,
that the same end may be attained without bending back the vessel, as has been
well observed by Hebeinstreit. It is scarcely explained how Laefiler could
have proposed to open the intercostal space a little further behind, leaving the
pleura untouched, in order to divide the artery at this point, and there apply
a tampon, without at all obstructing the flow of effused matters through the
first opening. Rejecting all these means, Bell found it more convenient to
seize with a hook the end of the bleeding vessel and tie it. There are some
who have had the courage to establish a point of compression over the wound
of the vessel for several days by the fingers of assistants, who relieved each
other alternately. In a word there is no kind of useless or unapplicable
resources which have not been devised for this occasion. None however have
remained in practice. Supposing it necessary to act, the hemorrhage may be
easily arrested, by pushing into the chest, in the manner of Desault and Zang,
the middle of a fine compress. After filling this species of sack with charpie
or tow, to transform its internal portion into a kind of ball, its external portion
will only have to be closed and drawn up so as to compress from within outwards
until the blood ceases to flow. This small apparatus can be fixed without the
least difficulty, by tying the free portion of linen over a second roll of charpie.
OPERATIVE SURGERY. 515
This means, the only one to which M. Larrey was willing to give assent, if from
any cause it is not deemed proper to make immediate union of the wound, being
applicable in every case, offering the advantage of being always at hand, and of
being within the reach of every one, should take rank of all the rest, and un-
questionably deserves to be substituted for them.
Art. 3. — Paracentesis of the Pericardium,
The idea of opening the pericardium when filled with serosity, pus, or blood,
at first appeared so bold that many still regard it as rash and inapplicable.
Timid surgeons have been deterred from it through fear of wounding the heart.
Others reject it, because it may provoke inflammation, which in consequence
of its locality would quickly bring on death. The difficulty of recognizing
the disease with certainty during life, and the danger of removing only a
symptom, is the argument which the most reasonable have advanced against it.
None of these different motives however is sufficient to proscribe it absolutely.
With the exploring means which the science at present possesses, the expe-
rienced practitioner will rarely fail of establishing with all desirable precision
the diagnosis of effusion in the pericardium. The heart can always be avoided.
By evacuating a morbid fluid from a serous membrane we free it from a foreign
body, and in this respect puncture is more calculated to diminish than to
excite inflammation. With the operation, the patient it is true runs great
risks; but without it he is devoted to a speedy and certain death. If para-
centesis does not cure, it may at least afford temporary relief. It is to be
regretted that experience furnishes scarcely any light, and that on a subject
so grave the ideas are purely theoretical. Senac, who is considered as having
committed a fault in first proposing puncture of the pericardium, gives no
case of it, and the observation attributed to him by Sprengel has reference to a
true hydrothorax. Van Swieten and H. Welse, to whom M. Rayer refers,
express themselves still more vaguely. Riolen who treats it as a common
proposition, does not however say that it had been performed in his time.
It is known that the pretended pericardium which Desault opened was nothing
more than accidental cyst. It does not appear that M. Skielderup has given
any thing conclusive in support of his advice. It is evident also that the col-
lection opened by M. Larrey had its seat without the envelope of the heart.
The three observations reported by M. Romero, the substance of which is also
given by M. Merat, are too incomplete not to leave a doubt upon the mind.
That which Mr. Jowet of London has published as a first successful case, in
182r, is equally incapable of removing all difficulty from the subject; but if
it still remains to be proved that paracentesis of the pericardium has ever been
performed on the living subject, there are not wanting facts to prove that per-
foration of this membrane does not necessarily produce death. The thesis of
M. Sanson jun. contains several. M. Larrey quotes several; and I myself
have met with one very remarkable. A coalman, who died of pneumonia at
the hospital of Improvement in 1824, had received some years beibre a stab
with a knife in the left side of the thorax. On opening his body, v/e found a
very old cellular band, which ran obliquely from the wall of the thorax to the
mediastinum, and was continuous with the anterior edge of the lung, which
adhered like it to the external surface of the pericardium. The point of this
516 NEW ELEMENTS OF
last organ, around which were spread the preceding bands, was pierced with
a round opening with thin edges, and capable of admitting the finger. The
corresponding region of the heart presented a cicatrix easy to be recognized,
but which we could not trace into the ventricle. The part was exhibited to the
Academy by M. Bougon the next day, and every member of that body can
confirm the correctness of what I say.
Manual. — In its natural condition the pericardium is accessible to the sur-
geon by a number of points. By distending it beyond measure, effusions ren-
der it still more easy to be reached.
Trepanning tlve Sternum, — Riolan advances, and others agree with him, that
tiie sternum may be trepanned at an inch above the xiphoid cartilage in per-
forming the puncture of the cardiac cyst. This doctrine, reintroduced as a
novelty with all its necessary details by M. Skielderup, has found some
followers among the moderns. Laennec among others adopts it, and
endeavors to deduce from it the advantages of avoiding with certainty the
internal mammary artery, of reaching infallibly the distended pouch, and of
not opening the pleura. Senac directed the fifth or sixth intercostal space to
be opened a little to the left of the sternum, and through this the trocar to be
plunged very obliquely downwards, and to the right into the collection to be
evacuated. In order not to wound the mammary artery, Desault mkde his
incision more outwardly, and entered the morbid sac only after feeling the
fiuctuation with his finger. This is also the mode praised by M. Romero,
who, instead of the trocar like Senac, or the blunt bistoury of Desault, preferred
scissors for dividing the envelope of the heart, after raising up a fold of it
with the forceps. Lastly, M. Larrey says that it is better to traverse from
below upwards the space which separates 'the left margin of the xiphoid appen-
dix from the cartilage of the last true rib ; that the pleura is thus spared with'
out any risk to the peritoneum, the diaphragm, or the internal mammary artery,
and that thus the most depe.nding point of the pericardium is reached.
Trepanning of the sternum is unquestionably the most simple process that
has been devised. The bone to be penetrated is soft, superficial, and devoid
of bloodvessels on both its surfaces. It allows the pericardium to be seen
and touched before being opened, and the last stage of the operation to be
abandoned ; the only one to excite apprehension if the surgeon have previously
mistaken the seat of the disease. The fluid cannot be poured into the pleura.
I see no other inconveniences, than that of occasioning a loss of substance
which renders immediate union of the wound difficult, and inevitably brings
the interior of the sac in contact with atmospheric air. But is it not better to
leave the puncture of the pericardium open than to close it before stopping
the source of the disorder ? In this case, is not the action of the air more to
be desired than dreaded ? The danger to the pleura, no matter what precau-
tions are taken to avoid it, and to the internal mammary artery in Senac's
method slightly modified by Desault, llemero, and Jowet, does not allow it to
be brought in comparison with the preceding method. The process of M.
Larrey, which may rigorously conduct to the same end as trepanning the
sternum, is not of so easy application as its inventor seems to think, on subjects
in whom oedema, infiltration, or natural embonpoint is sufficient to prevent the
skin from immediately touching the external face of the bones or cartilages of
the chest. Besides, the branch of the mammary artery, which crosses the
OPERATIVE SURGERY. 517
anterior face of the ensiform prolongation, is sometimes so considerable, that
a wound of it, which is almost inevitable, may create a troublesome hemorrhage.
It seems to me, therefore, prudent to act according to the advice of Riolan,
repeated by M. Boyer. The crown of the trepan is to be applied over the
left half of the sternum immediately above the xiphoid appendix, so as to fall
on the widest point of the anterior separation of the mediastinum. The left
index finger carried to the bottom of the wound will then afford certainty of
the fluctuation, and serve as a guide to the bistoury. The pericardium being
opened, it will be proper to turn the patient on his left side, and more than
ever to keep his chest in a position almost vertical, to give issue to the fluid,
which should be permitted to flow slowly. The dressing consists of a tent of
cliarpie carried to the orifice of the serous sac, a pledget of lint spread with
cerate, compresses, and a body bandage to keep the whole in place, as in, the
operation for empyema.
Injectiojis. — The idea of treating hydrops pericardii as an hydrocele, by
injecting an irritating fluid into the diseased membrane to provoke adhesive
inflammation, has nothing in it repugnant to sound reason, though some have
unjustly made it a crime in M. Richerand to have advanced the doctrine.
If besides the evacuation of the fluid the puncture does not itself produce
this adhesion, it is useless to rely on its success, except as a mere palliative.
The radical cure of hydrocardia without obliteration of the altered sac is no
more possible than that of hydrocele. If it has ever been obtained, it was
because the practitioner without intending it fulfilled the design proposed,
first by M. Richerand, and since by Laennec. Tlie contact of the air might
perhaps suffice to bring on the necessary degree of inflammation. When
there is no organic lesion, tepid water, or some other gently irritating fluid
should be first tried. If there is an effusion of pus, the injections should be
varied as in the treatment of empyema. In every mode I w ould direct the
opening in the pericardium to be large and kept open to the end. There
M^ould then be a treatment analogous to that of hydrocele by incision or ex-
cision, and the effusion which naturally follows an injection into the tunica
vaginalis after puncture, will not endanger its result. However, these are
but suppositions. Before according them any value, and applying them to
man, we ought by experiments on animals to determine to what extent they
are well founded. It is a point of practice which possesses considerable
interest. The rarity of occasions which call for their application, seems to
me to be the only plausible reason which diminishes their importance.
i
*n|ip^Bf'ilfe!P'
518 NEW ELEMENTS OF
CHAPTER III.
Abdomen.
SECTION I.
Effusions. — Cysts.
Art, 1. — Paracentesis,
Puncture of the abdomen in dropsy is one of the oldest operations in
surgery. To accidents, of which history furnishes examples without end,
is owing the first suggestion. Nothing in truth is more frequent in the
annals of science, than cases of ascites cured in consequence of a wound of
the abdomen. A child amusing itself one day with a knife in the yard of a
dropsical peasant, says Guyon de la Nauche, was thrown by one of its play
fellows upon the wretched patient, and cut open his abdomen. A large
quantity of water flowed from the wound, and at the end of some weeks the
patient was radically cured. Another ascitic, finding no surgeon willing to
make the puncture resolved upon doing it himself. As it had been forbid to
leave any thing in his way, which might enable him to accomplish his object,
he broke the glass he used for drinking, and shaped a piece, which he plunged
below the naval. A complete cure was the reward of his temerity. No doubt
the same remarks have given rise to the same ideas since the remotest
antiquity, and that paracentesis abdominis is as old as medicine.
Indication. — When ascites is the effect of an incurable alFection of any
organ contained within the abdomen, it is evident that puncture will not triumph
over it, and that in such case it can only be used for the temporary relief of
the patient. But if the dropsy is essential and idiopathic, the removal of the
eiFused fluid cannot but favor the action of the general treatment, and power-
fully conduce to the re-establishment of health. In the first case the opera-
tion should be deferred as long as possible, and resorted to only to prevent
suffocation. In the second, there would probably be an advantage in following
the advice of Duverney and Bertrand, renewed by M. Broussais, to give an
early issue to the effused fluid. It is so rare to see ascites terminate happily,
that, after the ineffectual employment of the means which experience seems
most to accredit, compression for example, which I saw once succeed in a ladi
fourteen years old, at the hospital of Tours in 1818, the advantages of which'
are praised by M. Godele of Soissons, the good effects of which were experi- j^
enced at the Hotel Dieu during the past year, and the efficacy of which has^
been placed beyond doubt by M. Bricheteau, it may well be permitted to
appeal to the operation, however feeble the chances of success. \
Examination of the Processes, — Red hot iron which was formerly in use,
caustic with which an escar was first made, which it was afterwards necessaryi
to divide in order to penetrate the peritoneum, and the seton proposed by *
others, have long since given place to more rational modes. The method of ^
OPERxlTIVE SURGERY. 519
Paulus Egineta and Guj de Chauliac, a method which was still praised by
Pigraj, and which consists in dividing the integuments with the histoiiry
between the pubis and the umbilicus, and then passing through the aponeurosis
or the muscles a little higher up, so as to make it possible to close at pleasure
the deeper opening, bj slipping over it the skin first divided, is also abandoned,
as well as all others which require a cutting instrument. The needle of
Thouvenot or of Barbette, evidently pointed out by Rhazes ;the instrument of
Block or Girault ; the trocar canula of Sanctorius, the invention of which
Camper refersas far back as Hippocrates, variously modified by other authors,
particularly by J. L. Petit, who made of it the very perfect instrument known
at present under the name of trocar or trois-quarts, render the puncture of the
abdomen so simple and easy, that for a century past there has been no more
discussion of the bistoury or the lancet than of the cautery, for penetrating
the peritoneum of an ascitic. Some modern surgeons however seem to have
revived the use of the incision. Dr. Physick, among others maintains that
the operation is much less painful with the lancet than with the trocar, and
Dorsey says, that in America this last instrument will soon fall intodisuetude.
More recently Mr. Calaway, a surgeon of London, has endeavored to prove
that the lancet should really have the preference in puncture of the abdomen.
Directed by the left index finger, which serves it as •A.point t?' appui, it is plunged
with the right hand into the linea alba above the pubis ; a female catheter is
then introduced into the peritoneum, and for the rest there is nothing peculiar
in the operation. This process, recommended by Petit-Radel in I'Ency-
clopedia Methodique, the same moreover with that of CceHus Aurelianus, may
be imitated without inconvenience, but it is doubtful whether it has in reality
any real advantage over the method adopted among ourselves. If the instru-
ment come in contact with any vascular branches, it infallibly divides them ;
and all the organs within its reach must share the same fate, while the trocar
turns aside and displaces rather than cuts the movable organs which present
themselves before it. The wound which results from its passage closes as
soon as it is withdrawn. That made by the lancet, on the contrary, remains
open, and offers no obstacle to the serosity which tends to lodge in it. The flat
trocar of Wilson, that of Andre, which according to the advice of B. Bell
many practitioners of Great Britain prefer to the instument of Petit, because
say they, it scarcely differs from a cutting instrument, is altogether unworthy
of tliis predilection. The jointed trocar, those with a conical point, or like a
serpent's tongue, or more or less flattened instead of being triangular, and the
fifty other forms recommended, scarcely deserve to be mentioned. That which
has received the approbation of French surgeons leaves something to be
desired, and the modifications of which it has been the subject since J. L. Petit
are only calculated to injure it.
Place of Election. — All points of the abdomen are not equally proper for
paracentesis. The left flank would be the most favorable when the spleen
is sound, if the epiploon, more extensive on this side, did not oppose an
obstacle to the flow of the liquid. On the right the presence of the liver is
to be feared. Too near Foupart^s ligament is found the sigmoid flexure of the
colon or the coecum. Posteriorly is the last false rib or the crista of the
OS innominatum and it would be easy to reach the lumbar colon. The sub-
umbilical zone corresponds to the transverse portion of the large intestine
520 NEW ELEMENTS OF
Quite loiv on the median line is found the bladder. However, it is necessary
to act on a depending point. The linea alba preferred bj the ancients, and
even now by most English surgeons, has no advantage in this respect: it is
far from being as free from liability to hemorrhage as is imagined. A large:
vein sometimes courses along its anterior face, Mr. S.Cooper mentions a
case in which more than a pint of blood flowed from the wound he made in
this place with a bistoury. In the female there is between the uterus and the
rectum, a cul de sac in the bottom of the pelvis, which maybe easily reached
through the posterior and superior part of the vagina. This point, the most
depending of all, would also be the most proper perhaps, if the peritoneum
was always free through its whole extent, if a change of relation of the;,
bladder of the uterus on the intestines did not expose some of these organs
to be perforated. We should therefore choose and conform to the precept of
H-enckel, of Watson, of Bishop, of Nosthig, only after being assured by the
touch that the serosity descends into the pelvic cavity, and tends to depress
the roof of the vagina. By penetrating through the rectum above the vesiculse
seminalis as some other practitioners direct, there would be still more danger
of wounding the bladder. The fear of then finding stercoracious fluids to
pass into the peritoneum, will always be reason enough to reject this mode,
although by way of exception it may be adopted in some subjects. Eveiy
mode of emptying tiie peritoneum of ascitic collections, even by puncturing the
bladder itself has been occasionally resorted to.
Berard gives a case of this in his thesis. There was thought to be an
ischury. The sound was carried forcibly through the urethra. Several pints
of serosity escaped. — The patient died. The autopsis proved that the subject
had been ascitic, and that the instrument had entered the abdomen. A Lon-
don surgeon, Mr. Watson, has seriously proposed to enter by this passage, and '
what is no less surprising, Mr. Buchanan, one of his countrymen, is said to
have performed it three times with success, but I do not think that among us
this precept will ever require a serious refutation. The scrotum which
answers best, as proved by the observations of Ledran and Morand, when
together with ascites there exists congenital hydrocele, can only be used in
this circumstance. If there be found a part of the abdominal parietes thinner
than the rest, in such a degree as to be formed of the skin alone, and having
acquired a kind of transparency, it is there that we should act, however
unfavorable it may be in other respects. The umbilicus, which often presents
this peculiarity, and was recommended by Lanfranc and the two Fabricii, is
the point wherein M. Ollivier, founded on an observation entirely his own,
^nd another of M. Bigat of Angers, proposes to perforate in pregnant women,
M. Scarpa, and after him M. Cruch direct, on the contrary, that during preg-
nancy the puncture be performed in the left hypochondria ; that is, a little
below the third false rib. I have several times had recourse to paracentesis
on women in a state of gestation ; among others, three times in the course of
one pregnancy ; and the whole extent of the left side, all the points of this
side where the trocar is usually inserted, appeared to me separated from the
uterus by a sufficient interspace to leave no great importance to the precepts of
Ollivier and Scarpa. A little without the linea alba, where the operation was
formerly performed according to the advice of Celsus, the epigastric artery
runs some risk. The middle of the space between the margin of the ribs and
OPERATIVE SURGERY. 521
the crista of the ileum, indicated bj Sabatier, would have the inconvenience
of being too near the chest, when the spleen and liver are the seat of an
engorgement; so that as a general rule the middle of a line drawn from the
umbilicus to the anterior spine of the ileum is still the best. The instrument
cannot touch either the bladder or uterus, unless it be very much developed;
or the epigastric arterj which runs within ; nor the anterior iliac artery which
is without ; nor the colon which is found below and behind. This place,
which the majority of operators have prescribed since Palfin suggested the
idea, is then the true place of election, and each of the others the place of
necessity. In ordinary ascites a wound of the intestines or their arteries is
almost impossible, the serosity naturally throws them towards the diaphragm
or the spine. Even when they remain free and floating, the mesentery is not
long enough for the trocar to reach them. But if adhesions fix a part of it
to the parietes of the abdomen, no doubt the instrument may open them and
give passage to fecal matter; cases of which have been reported. Encysted
dropsy y which has its seat in an ovary, in the cavities of the omenta, in a por-
tion of peritoneum bounded by adhesions, or in a peculiar accidental sac,
will also render the same tiling likely to occur. Surrounded by thicker walls
it obliges us to penetrate deeper before arriving at the cavity, and consequently
requires us to distinguish it if possible before commencing the operation.
Position of the Patient. — No one now advises the patient to be kept standing
during the operation. The sitting posture is not more proper except under
particular circumstances. He should be placed on his side near the edge of
the bed. While the liquid flows, an assistant on the opposite side, with both
hands spread out, moderately compresses the parietes of the abdomen.
Without this precaution, which the ancients neglected, the viscera and the large
vascular trunks being suddenly relieved from the pressure to which they had
been accustomed, occasion syncopes, lipothymiie, and convulsions, which it is
important to avoid. The bandage or corset invented by Monro to supply the
place of the assistant's hands, and serve as dressing after the operation, only
imperfectly fulfill the intention, and does not deserve the preference given it
by some. To apply it beforehand, to tighten it in proportion as the abdomen
is emptied, to keep opposite the proper place the hole which is in it for the
passage of the trocar, and then to fill the hollows that may be left in the iliac
regions, &c., are aiiairs too minute for surgeons to be confined to without
necessity. The cloth passed around the abdomen, its two extremities drawn
gradually by assistants while the water flows, as recommended by Mr. S. Cooper,
is still more improper. If the effusion has its seat in the peritoneum, it is
possible that the epiploon, a knuckle of intestine, a flake of albumen, or a
hydatid, may present at the extremity of the canula, and close it before the
complete extraction of serosity. A stylet or blunt staff carried through the
instrument is always sufficient to remove these obstacles, and clear the passage
for the fluid to run with its original freedom. Serous cysts, containing scarcely
ever any thing but limpid serosity, are generally free from this kind of incon-
venience ; but! dropsy of the ovary, which almost constantly forms an oily or
gelatinous substance more or less thick, rarely very fluid, presents sometimes,
and requires a canula of considerable size.
Extraction of the Fluid. — Many authors are of opinion that the whole of
the fluid ought not to be removed at once ; that it would be better only to take
522 NEW ELEMENTS OF
it Awaj gradually. With this intention, Pauliis Egineta, Guj de Chauliac,
&c., avoided piercing the skin and the peritoneum on the same level j in the
time of Hippocrates they placed a small canula in the v^^ound, which has been
modified a thousand times since, and which they employed as a kind of spigot
to stop and unstop at pleasure ; others drew off at first but a certain quantity
of the morbid fluid, repeating the same operation successively a greater or
less number of times ; and after opening the abdomen with a lancet it has been
proposed to let the matter issue of itself slowly and insensibly. But expe-
rience having obtained nothing very positive as to the value of such a mode,
it appeai^s more reasonable to leave in the abdomen only what cannot be
extracted. Exhaustion and syncope, which the ancients hoped thus to prevent,
are more certainly avoided by a bandage properly applied ; and patients would
be only half satisfied, if their abdomen was but half emptied after they have
♦submitted to be tapped.
Dressing. — The compressing bandage after tapping has not only the
advantage of supporting the viscera, but is also a powerful means of determining
a definite cure. The authentic cases adduced in support of this asser-
tion are now of sufficient number to induce us to multiply them more and
more. Last spring I was requested by Doctor Rousseau, physician at Bating-
noUs, to tap a child five years old, who had been affected with ascites for
eight months. We drew six pounds of limpid fluid from the abdomen. No
alteration of the viscera could be detected through the parietes of the abdomen.
An exact and moderate compression was immediately established. The
effusion was not reproduced and the little patient soon recovered his former
health. The mode of effecting compression in these cases should be left to
the invention of the operator. Whether it be made with a flannel bandage
as directed by Mr. S. Cooper after Bell, the bandage of Monroe, a kind of
lozenge terminating above in a shoulder strap, and below by straps for the
thighs, and so as to be properly fastened across, or quite simply, with a body
bandage and compresses, or other pieces variously folded over the epigastrium
and the sides, provided that it be exact and regular the rest is of little
importance.
Injections^ — Some think that the radical cure of ascites may be obtained by
another method after tapping. By inference from what happens in hydrocele
they dreAv the idea of throwing into the peritoneum irritating fluids to produce
adhesive inflammation. Brenner, who seems to have started the idea, and who
only wished to strengthen the viscera, proposed a mixture of camphorated
•spirits, aloes, and myrrh. W^arrick tried it with Bristol water and cured his
patient. Repeated with red wine and tar ivater the experiment had not the
same success. The two patients died. After making trial of the process
of Hales, who directed a canula to be placed each side of the abdomen, so that
the fluid might return by one as it was thrown in at the other, Warrick in the
end gave the preference to the Bristol waters and simple puncture. Although
since directed by Heuermann, Bossu, and some others, injections in ascites were
entirely proscribed until two years since, when the Annals of Broussais brought
forward in d\eir favor two cases of success obtained by the vapor of wine.
Emboldened by their example M. Lhomme attempted the same means on an
adult who had already been tapped several times. The result surpassed his
expectations. His patient, like the one of M. Gobert, continued to do well. A
OPERATIVE SURGERY. 523
subject so grave requires more conclusive facts to produce a decision. No-
thing proves that M. Lhomme really caused the vapor of ivine to pass into the
abdomen. He filled a syringe with it, as he says ; but the cloths wet with cold
water with which he thought it necessary to wrap the canula through which it
was obliged to pass, must necessarily have condensed it immediately ; so
that very probably it was the air and not the wine that was forced into the
abdominal cavity. The observations of Huermann, of Litre, of Garengeot,
o-f Bossu, seem only to relate to encysted dropsy, and those of Warrick or
Warren, are too incomplete to deserve great confidence. Yet it is not
improbable that important practical data may one day be drawn from these
attempts. Reasoning founded on several facts induces me to think that the
cure of ascites takes place only by the adhesion of the parietal peritoneum
with the abdominal viscera. The colics which are habitually felt by those
who have escaped this disease, and the obstruction which they meet with in
their digestive functions, are proof of the fact. A man about fifty years of
age, who had been cured of ascites fourteen years previously and who died of
pneumonia in the hospital of Tours, in 1817, a girl nineteen years old suc-
cessfully treated at fourteen years of age for a similar dropsy at the Paris hos-
pital for children, and who died in consequence of cerebral lesion in 1824
at the hospital of Improvement, had all the intestines glued to each other and
to the parietes of the abdomen by innumerable cellular lamellas and fila-
ments. Such being the fact the question remains whether prudence and
humanity may be allowed in these cases to attempt to imitate the process of
nature. For the purpose of elucidating this fact, M. Bretonneau made, in
1819, some experiments upon dogs. He first injected pure water, brandy
and water, and then a strong solution of muriate of soda, into the perito-
neum, but no inflammation could be produced in these animals, and all the
injected fluids were absorbed after several days. A patient whose condition
aftbrded no hope of success from the use of ordinary means, and who was
"threatened with near death was submitted to the same experiment. He sunk,
but it was under the progress of his disease, and because a part of the fluid
was infiltrated into the substance of the abdominal parietes and there produced
gangrenous erysipelas. M. J. Cloquet has several times mentioned to me a
patient in whom the vinous or alcoholic injection for a congenital hydrocele
passed against his intention into the abdomen, and who, after some trouble-
some symptoms, was finally restored to health. Without wishing to draw from
these various trials consequences which do not follow, I still think them wor-
thy of exciting attention. They tend to prove at least, that injections into
the peritoneum are not necessarily as dangerous as they are generally supposed;
and that before rejecting them absolutely, it would be well to make them the
subject of varied experiments and of profound and impartial examination.
This question is also presented under a new aspect by M. J.V. Roosbroeck of
Louvain, who being struck with the eminent diuretic and sudorific properties
of the oxidulous gas of Azote, resolved upon injecting it into the abdomen of
dropsical patients after tapping. Three patients, one male and two females,
thus treated by him, derived such advantage therefrom, that M. Broussais did
not hesitate to attempt it in turn, but on a subject whose condition was so de-
sperate that it occasioned surprise that he should survive eight days. The
author puts two drams of nitrate of ammonia into a glass vial to which he
524 NEW ELEMENTS Of
adapts a bladder and stopcock ; lutes the apparatus, and places it over the
flame of a spirit lamp ; when the bladder is full of gas from the decomposition
of the salt, unlutes it and lets the whole cool ; he then fixes the end of the
stopcock into the trocar canula and makes the injection. If no error has
glided into the statement of M. V. Roosbroeck, practitioners should un-
doubtedly be eager to repeat his experiments.
Sac of goldbeater^ s skin. — Will a bladder of this material, as applied to the
radical cure of hernia, proposed by M. Belmas, carried empty into the peri-
toneum or cavity of the cyst, and then blown up or filled with any appropriate
fluid, and fastened without by its extremity, have the advantage as this author
presumes of graduating the irritation at pleasure, or discontinuing it if
necessary by removing the foreign body which occasions it ? 1 cannot
think so.
Supposing nothing of this to be done, and that the effusion reappears, tapping
is to be repeated as often as it becomes necessary, by the rules laid down
above. There are patients whose life is thus prolonged for several years, in
whose cases we are obliged to have recourse to tapping every two or three
months* Dropsy of the ovary, a disease purely local in the greater number
of cases, supports best these repeated operations. Partial or encysted dropsy
may also, under some circumstances, admit of it ; but is doubtful whether
general ascites may be ranked in the same class, or continue long after
paracentesis v/ithout becoming fatal. Thus when it is asserted, that tapping
was performed nine times on the same woman by Saviard, eleven times by
Litre, twenty-nine times by Grew, fifty-seven times by Cheselden, forty-
seven times by Laub,* eighty -six times in the course of twenty-six years, by
Martineau, fifty-two times by Schmucker, sixty -five times by Mead, one
hundred times by Callisen, and even six hundered and fifty-five times by
Bezard, and that the fatal term of this disease has thereby been put off, it is
almost certain that they were cases of ovarial dropsy, and not of ascites, in
the proper acceptation of the term.
Manual. — The apparatus is composed of a trocar and canula of proper size,
smeared with cerate, a tub or any large vessel to receive the fluid, a smaller
and shallow vessel which may be held quite close to the abdomen, unless the
serosity flows with sufficient force to render it unnecessary, a piece of cere-
cloth, various compresses folded several times, a napkin to serve as a shield,
another folded treble and furnished with straps for the thighs and shoulders.
One assistant remains near the head, another near the feet and on the side
upon which the patient is laid, in order to support the chest and thighs. A
third, placed on the opposite side, and even on the bed for fear of being other-
v/ise too much fatigued, holds himself in readiness to place his extended
hands over the whole surface of the abdomen to compress it gently as the
water flows. The surgeon takes the trocar and plunges it with his right
hand through the abdominal wall, the integuments of which are kept stretched
with the left. AVhen inserted briskly and suddenly, the instruments create
scarcely any pain to the patient. Many authors, fearing it may go too deeply,
and touch some of the viscera, prefer entering it slowly, turning it on its axis,
and contend that in this way the arteries are more certainly protected from
wound. These reasons have no foundation. The organs of the abdomen, as
I have already said, are too remote from its parietes, in ascites, for the trocar
OPERATIVE SURGERY. 525
to reach them, although carried in as far as its handle. Making a point
d^appuion the skin with the two last fingers during the insertion is not much
more necessary. Moreover, so many precautions only render the operation
more long and fearful. The index finger held alongside the trocar while the
handle is held firmly in the palm of the hand, leaves uncovered only as much
as desired, and only what is necessary to arrive at the region of the fluid, and
is sufficient for tlie security of the viscera. If the parietes of the abdomen or
the cyst are one, two, or three inches in thickness, sufficient in fine to cause
embarrassment, of which Saviard is said to liave met with a case, if they are
so flabby as to yield under the pressure, another instrument is to be employed,
and it is in this case that the lancet or bistoury may with some advantage be
preferred. The want of resistance announces when it has entered the peri-
toneum. The canula which is to remain in its place, its head turned down-
wards, is held by the left thumb and forefinger while the trocar is w itlidrawn.
The liquid gushes out immediately with more or less force, and by a jet very
easy to conduct into the bucket designed for this purpose. The buttoned
stylet, the chest probe, &c., are only used when some foreign body stops up
the canula. After all the water has been drawn off*, the operator removes
the tube, rotating it and supporting, at the same time with the first two fingers
of the other hand, the periphery of the orifice he has made, to prevent the skin
from being pulled ; he then applies the plaster and compresses over this point,
covers thus the whole front of the abdomen and the sides, fixes the body
bandage, and immediately replaces the patient in bed in the least fatiguing
posture.
Occidents. — Hemorrhage from tapping, although rare, is yet the inconveni-
ence which has the most occupied practitioners. Mr. C. Smith has collected
ten instances. It is easily remedied when it arises from a wound of the
epigastric artery or any other vessel of the abdominal parietes. For this
there are several means, one of them, used in the last century, recommended
by Petit Radel, and recently employed with success by M. Cruveilhier, con-
sists in including the whole course of the trocar in a large fold of the soft
parts, in compressing or even bruising it a little with the thumb and forefinger
until the blood ceases to flow. A small plug of wax, an end of bougie, shaped
into a faucet, as devised by Bellocq, or still better a piece of gumelastic or
plastic bougie, such as used for the urethra, pushed into the wound so as to
fill it exactly, is a resource which seems quite sufficient in this respect. I am
not certain however that a piece of prepared sponge would not do better.
By imbibing the liquid at the bottom of the wound, this substance will evi-
dently exercise an eccentric compression most advantageously, but it may also
happen to break when it becomes necessary to remove it. If instead of
escaping without, the blood accumulates within, it will be difficult to perceive
it before death. Besides; supposing the contrary, the surgeon would be
scarcely better off. What then is to be done in such a case ? or where must
we look for the deep-seated vessel, which supplies the hemorrhage ? For the
rest, we must not be imposed upon by appearances. There is sometimes
observed on the surface of serous membranes, a sanguineous exudations©
abundant as to give to the dropsical fluid the dark color of venous blood, so
that at first sight we might suppose it blood and not serosity that flows through
the wound. There was a beautiful example of this in an adult affected
526 NEW ELEMENTS OF
with hydrothorax at the hospital St. Antoine, under the care of M. Rayer,
while I performed the surgical duty of that establishment, and no doubt the
same phenomena may be met with in the peritoneum. The hemorrhage, in
consequence of tapping in the median line, mentioned by Mr. S. Cooper, may
have belonged to this species. Supposing that the case observed at La Cha-
rite in 1824, is not to be referred to pure and simple wound of the epigastric
artery, it may be better explained in this way than by a pretended lesion of a
mesenteric vessel. M. Piedagnel however relates a case of abundant effusion
produced by puncture of an epiploic artery.
Art, 2. — Humoral Tumors of the Liver.
Abscesses, hydatiferous cysts, and encysted dropsy of the liver, have for a
long time been regarded by many persons as above all surgical resources.
The difficulty of recognising them during life, the fear of producing effusion
into the peritoneum, and of the action of the air upon the parietes of the cyst,
!iave generally caused artificial opening to be rejected. However, cases are
quoted of cures obtained by means of tapping with the trocar or with caustic
potass. Again ; incision having of late been the subject of special research,
and ?.!. Hecamier having arrived at the happiest results by combining these
several means, I have concluded to make it the subject of a separate article.
Tapping alone will be insufficient when the cyst contains any thing besides
limpid serosity. Moreover, it would cause effusion of a certain quantity of
fluid into the abdomen, if the protecting adhesions have failed of being esta-
blished around its course. The use of the bistoury renders this last accident
much more likely, and it can only be proper in cases where the diagnosis
leaves no doubt of the anatomical relations of the cyst. Caustics, it is said,
acting too slowly, are apt to produce general peritonitis in consequence of the
local inflammation resulting from their application. In the process of M.
Recamier, potass is first applied on several points very near the morbid pro-
tuberance, so as to produce by their union a large eschar, which is divided
after some days with a cutting instrument. Another dose of caustic is applied
to the bottom of the wound, which is to act more in depth tlian width. Re-
peated thus successively, cauterization determines with certainty adhesion of
the hepatic peritoneum with the peritoneum of the abdominal parietes, and
even places the part in condition for the trocar or bistoury to enter the cyst
as soon as fluctuation is perceived by the finger beneath the divided eschar.
After extracting all the fluid, M. Recamier replaces it by medicated injec-
tions, which he renews every day, and retains in the morbid cavity from one
dressing to the other by closing the wound with a plug of lint or sponge. By
this .means the action of the air is prevented, the pus, diluted as soon as pro-
duced, cannot stagnate nor pass into a putrid state in the interior of the cavity,
and the sac, closing by degrees upon itself, in the end transforms the whole
into a simple fistula, which generally is not long in cicatrizing. It is hardly
necessary to add that the same treatment is applicable to tumors of the gall
bladder, whenever they are found in the conditions established and so well
described by J. L. Petit. To make clear the diagnosis in every affection of
which we have just been treating, it is often necessary to make an exploring
puncture with a very small trocar or a cataract needle, as for distinguishing
OPERATIVE SURGERY. 52T
with certainty an aneurism from an abscess. M. Recamier remarks with jus-
tice, that in this case the instrument should I5e very fine, and withdrawn
briskly from the tissues. Otherwise there will be a wound through which
the fluid may become extravasated in the abdomen, or the neighboring organic
tissues. From these united precautions, successes, numerous and beyond all
expectation have been obtained at the Hotel Dieu of Paris, within a certain
number of years.
Another mode of opening morbid collections in the liver or abdomen,
proposed in 1827 by Mr. Graves of Dublin, merits a place beside the preceding.
This surgeon uses only the bistoury. After cutting freely through all the tissues
to within one or two lines of the collection, he stops, fills the wound with
lint, and waits until, in a fit of coughing, &c., the tumor opens spontaneously at
the bottom of the wound. Mr. Begin has since proposed for all purulent
abdominal collections to go thus, layer by layer, as far as the peritoneum, and
rest here if there is no adhesion, but if there is to penetrate at once into the
cyst. If the tumor be still free, the wound of'the peritoneum, which it imme-
diately tends to fill, promptly adheres to it by its anterior face, and three or four
davs after the instrument may be plunged in without fear of any effusion into
the abdomen. Facts sufficiently conclusive have been reported in England
and France in favor of this ingenious method.
^rt. 3. — Cysts and Tumors of the Interior of the Abdomen.
The ovary is often the seat of a degeneration which authors of every age
have noticed, but relief of which has scarcely been thought of except within
a century. Le Dran, Housson, Garengeot, had already remarked that tapping
scarcely ever removed it, while it was sometimes cured by largely incising the
cyst. Morand even advances that extirpation of the diseased organ ought to
be performed from the beginning to arrest its development. Observations,
communicated by Delaporte and Lieutaud, were summoned in support of this
operation, of which Thumin already gives the process, and which two English
physicians, Darwin and Power, warmly defended ; but, notwithstanding the
efforts of M. d'Ischier, the success obtained by Laumonier, the cure of Madame
de Choiseul, and the three cases reported by Kapser, the idea of Morand
remained without application, when in 1825 Mr. Lizars undertook to invite
attention to it, and on their part Messrs. McDowell, Nathan and Alban Smith,
put it in trial in America, and MM. Dieffenbach, Chrysmer, and Martini, en-
deavored to introduce it in Germany. At present a sufficient number of
cases are extant to enable us to put a just estimate upon extirpation of the
ovaries. Laying aside the operation formerly practised by Lemman, that
published by M. Lafflize of Nantes, another of M. Delpech of Montpelier, I
will confine myself to the enumeration of the most important — those which
have been reported from ten to twenty years since in the scientific journals.
The tumor removed by Dr. McDowell in 1809 weighed fifteen pounds, the
cure was effected by the thirty-fifth day. In another patient. Dr. McDowell
finding both ovaries effected made an incision, a quantity of blood flowed
into the abdomen, yet the operation was attended with full success. A negress
was relieved by liim in 1816 of an ovary weighing six pounds, and was also
cured. Two other women whom he treated in the same manner were not so
5£8 NEW ELEMENTS Or
fortunate; in one the disease remained, the other died. M. Dzondi of Halle
succeeded once by means of incision, the use of tents, and subsequent extir-
pation of the mortified cyst. Pure and simple extirpation performed in 1821
by Mr. Smith was not followed by any accident. The tumor removed by M.
Lizars the Srth February 1825, was as large as the uterus at full term. It
was necessary to prolong the wound of the abdomen from the xiphoid car-
tilage to the pubis. The other overy was equally affected, and yet the patient,
thirty-six years old, was finally restored to health. Dr. Chrysmer, in the case
of a woman thirty-eight years old, had every reason to congratulate himself
for having decided on the operation ; at the end of six weeks the patient was
able to return home. On the 6th May, 1822, Dr. A. Smith, operating on a
young woman, extracted the cyst after removing six pints of fluid, and stran-
gulating it at its base with a strong ligature which came away in a month and
a half afterwards. In 1824 this lady enjoyed the most perfect health. To
these cases of real extirpation attended with success, must be added others in
which the tumor has not been wholly removed, or the operation has not been
finished as proposed before commencing. In this manner for instance. Dr.
Lizars, finding * simple adherent mass in front of the sacro-iliac symphysis,
instead of an enormous cyst as he had anticipated, thought proper to confine
himself to the first stage of the operation, viz, the incision of the abdominal
parietes ; closing the wound immediately, he was so fortunate as to save his
patient. Mr. Grenville seeing in another case that it would be with difficulty
that the cyst could be separated from the surrounding parts, contented him-
self with incising it largely and emptying it carefully. This conduct gave
him complete success. M. Dieflfenbach, startled at the size of the base of the
tumor and the vessels it contained, seeing moreover that nothing but blood
flowed from puncture of its centre, did not dare to remove it, but immediately
closed the wound, and the patient was also cured. Mr, Galenzowski of
Wilna discovering that the tumor was too adherent to be removed, emptied it
by a large orifice, tore down its different cells, passed a thread through its
deeper wall, drew it towards the wound, to prevent all effusion into the perito-
neum, closed in the best manner he could the division of the abdominal pari-
etes, and obtained by this means an entire cure in the course of several weeks.
Other attempts have been less fortunate.
A woman forty years old, treated the 20th September 1 822 by Dr. McDowell,
died on the morning of the 24th. Dr. A. Smith, arrested by intimate and
very extensive adhesions of an ovarian tumor in a patient who had tapped
herself more than twenty -four times, confined himself to incision of the pari-
etes of the abdomen, and did not venture to finish his operation. He had how-
ever the misfortune to see this woman die on the forty-second day. The
patient operated upon by Mr. Lizars on the 22d March 1825, died the next
day. The one operated upon by M. Hopper and Chrysmer survived only
thirty-six hours. Another by M. Chrysmer alone was not more fortunate.
Lastly, the young woman whose case is given by M. Martini also died after
thirty-six hours. Although dangerous, extirpation of the ovary does not the
less constitute a resource worthy of examination. The ovary is not so in-
dispensable to the support of life but that the woman may be deprived of it
without too much danger. The gelders of beasts, who travel round the coun-
try exercising their profession, remove them without the least fear in the first
OPERATIVE SURGERY. 529
weeks from all the female pigs, and I can affirm that in their hands the opera-
tion is seldom followed by bad results. Diemerbroech, relates, from Athe-
naeus, that Adrametes, and fromSuidas, that Gyges king of Syria thus treated
the women of their kingdom. Alexander ab Alexandro says the same of the
Creophasji and the Egyptians. Wierus relates, that a gelder suspecting the
virtue of his daughter opened her abdomen, drew out the uterus to excise the
ovaries, and that this barbarous operation had full success.. Franckenau, Pott,
Lassus, M. Deneux cite each a case of extirpation of the ovary which did
not prevent the woman from doing well afterwards. The operation is of itself
neither delicate nor difficult. The occasions of performing it are but two fre-
quent. The diseases which require it if left to the resources of the system,
almost constantly cause death. But for it to offer a chance of success, the
tumor should be movable, not adhering to the intestines, easily separable
from all the abdominal organs, with a root or pedicle not too large, and not
exposing too many large vessels to be wounded. Moreover it must be known
and distinguished from every other disease, which is far from being always
easyi At first how are we to avoid confounding it with any tumor whatever
adjoining the uterus, the iliac fossae, &c.? Besides, who will then be bold
enough to propose the operation ? Later, when it occupies a great part of the
abdomen, the new relations contracted by the organs surrounding it and the
almost inevitable adhesions of its periphery, render its dissection and removal
if not impossible at least extremely dangerous. In fine, although incurable
from its nature, it ordinarily brings on death but very slowly. As a medium
term it allows, not as Mr Corbin believes twelve years, but five or six to
women affected with it. However, if as it generally happens in this case the
general health is preserved in a manner to contrast with the diseased condition
of the abdomen, if the issue of an unctuous or gelatinous fluid obtained by an
exploring puncture, demonstrates that the disease is in the ovary, if the tumor
does not exceed in size the head of an adult, and if the patient desires it
earnestly, we should attempt the operation. It only remains to be determined
if simple incision according to the principles laid down in the preceding article,
with which M. Portal, Denman, Ray, and Ransden, arc said to have been suc-
cessful, ought not to be preferred to extirpation.
Manual. — Laid on her back, the pelvis members moderately extended and
fixed by assistants, the woman ought to be placed so that the most prominent
part of the cyst may naturally present to the operator. He first makes an
iiicision parallel with the axis of the body, four, six, or eight inches long, on
the niost proper part of the abdomen, using the index finger of the left hand
to direct the bistoury as soon as the peritoneum is opened, and then engages
with the tumor. Is it free, movable, easily insulated, and its pedicle narrow,
tlie surgeon has only to tie its root firmly, and excise it outside of the ligature
v/ith the bistoury or scissors. Are the adhesions uniting it with the surround-
ing tissues small and easily destroyed, he removes them by careful dissec-
tion, and acts as to the rest as in the former case. If it be fungous, with a
broad base, with large blood vessels, it will be better not to touch it, but to close
the wound. If the adhesions to the parietes of the abdomen dp not permit its
removal, we should plunge a bistoury into it and open it largely, so as to
empty it entirely, and act so that the cyst may be gradually, drawn through
the wound of the abdomen. Position, adhesive plasters, or the suture should
67
530 NEW ELEMENTS OF
be employed, according to the case, to unite the division ; which should in
other respects be dressed as simply as possible. When the solution of con-
tinuity is very extensive, the intestines have such a tendency to escape that
the suture is then quite indispensable. It is nearly tha same when in the re-
moval of the tumor it was not necessary to open n r to occasion a great waste
in the interior of the abdomen. It is quite the reverse when the cyst only is
opened, or when it has not been possible to remove all that it had been in-
tended to destroy. Supposing that we wished to confine ourselves to incision,
we must first guard against eftusion, and produce in the first place protect-
ing adhesions, if they do not already exist, between the morbid mass and the
parietes of the abdomen ; and act in short as for an abdominal abscess or a
hepatic collection.
SECTION II.
Hernia.
A. HERNIA IN GENERAL.
Jlrt, 1. — Radical Cure,
Whatever be the seat of hernia, it forms always an infirmity if not a
disease so troublesome, as to require our efforts not only to palliate but to
permanently cure it.
The strange idea of the ancients in ranking it among the shameful disor-
ders, an idea still entertained in such a manner that the resident in the coun-
try often opposes secretly the symptoms to which it gives rise, rather than
complain to a physician, presented a bait too tempting not to be turned by
cmpyricism to the best advantage. Thus in the days of Hippocrates, Galen,
and Celsus, and in the present, were there pretended curers, herniary physi-
cians, occupied singly with the treatment of this disorder. It would be un-
just however to blame without exception the numerous attempts that have
been made to obtain a permanent cure, even since the art possessed excellent
means of retaining it. Laborers, who are the most generally afiected with it,
derive but little advantage from palliatives. The most perfect bandages are
far from producing for them the success obtained to persons of a higher class.
The cushion leaves the ring nearly always after several days or weeks, and
often the whole of the truss soon proves a new source of danger.
§ 1. Topical Remedies^ Compression y Position.
The emplastrum contra rupturam of the ancients, the brick cerate of J. Fa-
bricius, Verduc's vinegar bags, sandal wood, tormentilla, turpentine, the
topical applications of Babynet and Mdlle. Devaux ; the famous remedy of
the prior of Cabriere, which consists in red wine being applied to the hernia,
and muriatic acid taken internally, the cataplasm of iron filings, while load-
stone is taken internally, advised by A. Pare ; the decoction of dogs^-grass
and of were-wolf used by Arnaud ; the carbonate of ammonia mentioned by
M. Bel mas, and a thousand other means of the same description, at present
OPERATIVE SURGERY. 531
find no defenders except among quacks and old women. It is otherwise witli
compression, recommended by Celsus, Norsia, Blegnj, Trecourt, J. L. Petit,
Juville, &c. Maintained with perseverance, and properly applied, it has fre-
quently produced a definitive cure without requiring to be raised to the point
of determining gangrene as was advised in Germany more than half a cen-
tury since. Quite recently M. Beaumont, in a particular treatise, and M.
Duplat of Lyons, in a memoir addressed to the academy, have endeavored
to reinstate it in the good opinion of practitioners, by maintaining that com-
bined with astringents it can cure nearly every hernia. A surgeon of Pro-
vence, M. Ravin, states also as a certainty, that topical astringents and com-
pression can radically cure hernia at every age. These means with him
however are only secondary, the foundation of his method being the horizon-
tal position of his patient for whole months. The observations of Riviere,
F. de Hilden, Reneaume, Arnaud, and Hey, and the thesis of Rieck, show
all the benefit to be derived from the treatment proposed by M. Ravin — a
treatment which is said to have been generally used in Denmark in the time
of Winslow; but besides the uncertainty of success, what patient would
consent to remain in bed six months or a year for a tumor which is so easy
to retain by means of a simple bandage ^ The examination of these various
resources belonging properly to pathology, I can only give them a passing
notice, without pretending to fix their value or disadvantages.
§ 2. Various Operations,
The principal operations which have been put in practice for obtaining the
radical cure of ruptures, are cauterization, the ligature, the suture, incision,
excision, scarifications, dilatations, and closing of the ring.
1. Cauterization. — If it were sufficient in order to cause an operation to
be proscribed, to point out its dangers and cruelty, and demonstrate its inu-
tility, cauterization so frequently employed in tlie times of Albucasis, Rogei-,
and Guy de Chauliac, had not been extolled by so many practitioners at dif-
ferent epochs. But by denying the success it has really procured, in holding
as nought whatever of advantage it may offer, its antagonists have more than
once given the victory to those who were endeavoring to spread its practice.
Avicenna speaks of surgeons who laid bare the hernia, raised up its internal
envelope without opening it, and cauterized deeply the ring with red hot
iron. Others, Franco for example, opened the sac and merely touched its
neck with fire. A number of chymical caustics have been employed for the
same purpose. The escharotic oil, mentioned by J. Fabricius; the sulphuric
acid of the empiric Littleton, and which another quack found means to pro-
pagate in Paris in the time of Arnaud ; the muriate of antimony, potassa,
essence of euphorbia, ranunculi, &c., have each in turn been tried. It was
with the oil of vitriol that Maget, supported by Gauthier, soon after unmasked
by Bordenave in the academy, obtained in 1773 the pretended cures which
induced him to solicit the favor of government, and v/hich caused the death
of the celebrated Condamine. The potential cautery was applied on the skin
in the form of a train, or on a circumscribed point towards the neck of the
hernia, for the purpose of there producing an eschar, and causing the sac to
suppurate after perforating it. It appears however that Monrp and the naval
532 NEW ELEMENTS OF
surgeon spoken of by Sabatier, applied their escharotic also to the interior of
the sac. Thus considered, cauterization includes two quite distinct methods,,
one M'hich relates to the herniary tunics, the other which attacks on the con-
trary the orifice through which the organs are displaced. The first has the
disadvantage of being liable not to penetrate sufficiently deep at first, or in
the opposite case, of injuring the intestine itself; the inflammation it deter-
mines cannot be limited to the sac, may reach the peritoneum, and thus cause
tlie death of the patient. The second, which is not more entirely free from
this last danger, offers at least the resource of saving with more certainty the
viscera, since the operator commences by exposing them and pushing them
back into the abdomen. It must be added that this alone offers any chance of
success. It is in this way, when the eschar formed at the opening of a hernia
has been occasioned by actual cautery or any chemical substance, it leaves,
as a consequence, an ulceration which can be cauterized only by the second
intention. But as every cicatiix which is not the effect of an immediate
coaptation of the tissues, is soon converted into a firm and elastic layer, it is
readily understood what kind of barrier may be opposed to the reproduction
of hernia ; whereas the method which may be termed mediate, admitting even
the most complete success, will have no other effect than the closure or oblite-
ration of the sac.
2. Ligature. — The manner of applying a ligature around hernias when radi-
cal cure is intended, is by no means the same with all authors. Some apply
it immediately on the sac, others on the skin without any previous incision.
Pare saw some who made a circular incision, at the bottom of which they tied
a thread. Since the time of Paul many practitioners had also recourse to
the furrow, but many of them afterwards opened the whole sac to be certain
that no organ was included, in the ligature. Guy de Chauiiac says, that the
sac is first to be laid bare, in order to be seized and strangulated more surely
at its base. Among those who were content with the mediate ligature, there
were some, like Thevenin, who traversed the whole pouch with a double thread
and tied its two halves separately. J. L. Petit, who has slightly modified this
process, pretends to have derived great advantages therefrom. Others, men-
tioned by Celsus, placed the integuments between two plates of wood, and
compressed them as with pincers until they became gangrenous. In fine, the
oldest process, that adopted by Saviaixl and Desault, consists in tying circu-
larly the neck of all the herniary envelopes so as to produce mortification
more or less promptly. This method, less barbarous and terrible than cau-
tery, has evidently had a certain degree of success. If Lassus had better
understood its mechanism, he would not have called in question the instances
given by Bichat, from the practice of Desault. There is every reason to
suppose that the medical societies of I^yons and Paris would not so formally
have proscribed it in 1812, when M.Martin addressed to them his work
with a view to revive it, if they had fixed their attention on the nature of the
inodular tissue, which ulceration produced by the thread leaves in its course.
No doubt, after the destruction of the integuments, it forms in front of the
ring a cicatrix so firm as to render the escape of the viscera very difficult, and
thus affords some chance of a complete cure. However, as it does not fail
to be very painful at times, to create danger of peritonitis, and pinch some
portion of the viscera, unless very great attention has been given to it, and
OPERATIVE SURGERY. 533
as on the other hand, umbilical hernia of infancy, to which it is peculiarly
applicable, is often cured without any assistance, or under the influence of a
simple bandage, this operation scarcely deserves to be recalled from the obli-
vion into which it is fallen, and the success recently obtained from it by M.
Bal, does not more enhance its valufe than the constant success which it is
said to have upon colts.
3. Suture, The suture which is limited to sewing up the sac after it has
been incised, or simply emptied, is at first much more dangerous than the
ligature as practised by Desault, since it requires a dissection sometimes very
tedious before it can be effected — and thpndoes not necessarily cause the for-
mation of an elastic cicatrix, since it is not accompanied with loss of substance,
and has no other end than the obliteration of the sac — it is evident that it must
have less efficacy than the first against the return of the disease. Besides it is
not a generaf method ; it belongs specially to inguinal hernia in men the same
as castration, consequently it is unnecessary for me to dwell longer upon it
at present.
4. Incision, Incision has been long considered as an excellent means for
the radical cure of ruptures. It is only siAce the beginning of the last century
that surgeons have abandoned it. All the tunics and the sac itself were
divided as for strangulated hernia. The viscera being reduced, the dressings
were applied, and the wound brought to cicatrization as in the last case. The
obliteration of the sac was to be the result of the manoeuvre, and the operator
hoped by this to render tlie patient secure against all further escape of the in-
testines from the abdomen. Practitioners soon discovered that the question,
had not been presented in its proper light. J. L. Petit, yielding to the
advice of Arnaud against his own conviction afterwards seriously repented it.
One of his patients died on the fifth day. He was witness of another similar
case, and it was only after running the greatest risk that a third was restored
to health. Acrel, Sharp, Richter, Abcrnethy, &c., in pointing out the same
dangers, have also shown that incision of hernia is of itself much more formi-
dable than Lieutaud and Leblanc imagine. Huermann and a great number of
other practitioners after him, having remarked on the other hand that it does
not even succeed in preventing a return of the disease, that persons operated
upon for strangulated hernia are nevertheless obliged to wear a truss, it is not
astonishing that tliey have banished this surgical resource from practice.
5. Excision. If incision could not be retained in practice, with much
more reason should excision be proscribed. We cannot in truth dissect, insu-
late, and remove the sac after opening it, as Bertrandi advises, without in-
creasing still more the difficulties of herniotomy. In merely excising opposite
the ring, a disk including the whole thickness of the envelopes of the tumor
previously reduced, as also directed by Lanfranc, we may equally produce
peritonites and moreover wound the viscera if they adhere to the interior of ■
the sac. The excision of the w^hole herniary sac, it is plain, would be attended
with still greater dangers. It is truly painful to find the detail of opera-
tions of this kind in the works of Arnaud, Schmucker, and other mope
modern surgeons.
6. Dilatation. — Scarifications. Instead of excising the sac, after incising
it largely, Leblanc conceived the idea of applying to the radical cure of hernia
dilitation of the ring, already praised by the older surgeons, but particularly by
534 NEW ELEMENTS OF
Arnaud, for removing the stricture. Such a design if ever seriously proposed
would refute itself. The idea of scarifying the ring, an idea which is referred
to Leonidas, is less strange ; and Richter did not perhaps feel the full value
of his assertion when he said that small incisions increase greatly the adhe-
sions which naturally follow the operation. The eiFusion of lymph which is
almost the necessary result, procures effectually the chance of seeing all the
tissues mingle at the opening of the sac, and the ring definitively closed. If
J. L. Petit and Heister had made this remark, they could not certainly have
maintained that scarifications are more proper to relax than to strengthen the
canal or hernial opening. It is evidently to the same omission that must be
attributed the contempt of Lassus for this process, and the silence on this
subject of the greater part of modern authors. The principal reproach that
attaches to it is its presenting the same dangers as incision, of which after all
it is but a simple modification. As to the chances of success, it is assuredly
one of those which offer the most. In this respect it is therefore as worthy
and even more worthy of attracting attention than any other.
7. Br, Jameson^s method. The radical cure of hernia has always been
sought for with such avidity by patients, that the need of obtaining it has
never ceased to torment surgeons, and in our days many means are still pro-
posed for this end. That of Dr. Jameson of Baltimore deserves particular
mention, as much on account of its originality as of its real importance. A
woman operated upon with success by this surgeon for strangulated hernia,
being much troubled at seeing her disease return after several months, com-
plained to him and desired to be freed from it at any cost. The hernia was
crural. Having exposed the ring, Dr. Jameson cut, at the expence of the
neighboring integuments, a lancet shaped flap, two inches long and ten lines
wide, having its root on the side of the first wound, carefully dissecting it, to
invert and introduce its floating portion into the hernial opening ; fixed it in
this place by uniting the solution of continuity which he had just made by
several stitches, and supported the whole with an appropriate bandage. The
patient was completely cured, and there is every reason to believe that the
stopper engaged in the crural canal became engrafted there as in rhinoplas-
rnus, &c. At first view we discover nothing but what is ingenious in the me-
thod, and can comprehend all its elements. If on the one part, it is more
complicated, more painful, and at least as dangerous as incision and scarifi-
cation, on the other it seems capable of giving much more certain results,
since by this means we are sure of entirely preventing the egress of the
viscera. However, to appreciate its value from a thorough knowledge of the
case, facts are necessary, and science as yet possesses but the one. I will
even add that this case has not all desirable authenticity; that we can
scarcely understand how, through respect for the wishes of his patient, Dr."
Jameson could have consented to have but a chambermaid for assistant and
witness of the operation. So much mystery would be capable of raising
doubts in the mind of the least suspicious reader.
8. Method of M. Belmas. More recently, in 1829, and by a chain of ideas
with which I have nothing to do here, M. Belmas arrived at the invention of
a new metliod, whicli seems to him easier, more certain, and less dangerous
than all others. He directs a small pouch of goldbeater's skin filled with air
to be cai'rieil in and fixed to the superior part of the hernial sac. The plastic
OPERATIVE SURGERY. 535
matter which is not long in being eftused, penetrates the parietes of this foreign
body and in some measure combines with it. The whole becomes organized,
contracts adhesions with the ring or the neck of the sac, is transformed by
degrees into a solid lump, and in the end opposes an almost insurmountable
barrier to the viscera. Numerous experiments upon dogs, support the asser-
tions of M. Belmas. It remained to make application of it upon man; which
first took place upon M. Plessys, a gentleman fifty-four years old who had had
an inguinal entero-epiplocele for about thirty-four years. The operation per-
formed by M. Belmas was followed by no accident but by perfect success.
Encouraged by so splendid a result the author communicated his process to
M. Dupuytren, requesting him to try it on a lad fourteen years old who was
then at Hotel -Dieu for a congenital hernia combined with hydrocele. Vari-
ous incidents rendered the operation long and fatiguing. Alarming symptoms
followed and caused much apprehension for ten days, so as to induce M. Bel-
mas to have the patient removed to his own house that he might watch him the
better. However his health was gradually restored, and towards the end of
the second month the hernia as well as the hydrocele were radically cured.
A third attempt, made by M. Belmas assisted by M. Jaquemin at the Madelo-
nettes, on a prostitute affected with syphilis and umbilical hernia, was not so
regular as to allow any strict conclusion to be drawn from it. A solid and
permanent cure was nevertheless the consequence of this attempt, in other
respects so incomplete. In a fourth subject fifty-seven years old afiiicted
with a hydro-sarcocele, M. Belmas wished to see if his method would succeed
at least in closing the ring and curing the hydrocele. The pouch became so-
lidified about the summit of the tunica vaginalis which was inflamed, and
which it was necessary to empty of a sero purulent matter with which the in-
flammation had filled it. In fine, a fifth trial was made by myself, assisted by
M. Belmas at La Pitie, in the month of November 1830, upon a man about
sixty years old, who had had two inguinal hernias for a long time, and who at
his entrance into the hospital showed some symptoms of strangulation, and died
in consequence of gangrenous erysipelas. But various circumstances unne-
cessary to relate at present are sufficient to cause this essay not to be reckoned.
The first of these cases seems to confirm all the hopes of M. Belmas. The
fourth, that of hydro-sarcocele has, in my opinion but little value with
respect to the principal question, and hardly deserves to be noticed. The
other three alone truly complicate this problem ; still it must be confessed
that one of them, that of the prostitute, of itself proves nothing for or against
the method. The child operated on by M. Dupuytren, seems to have been
seized with inflammation of the gastro -intestinal passages and not peritonitis.
In the case which I observed, very strange symptoms were manifested, and
the material remote cause of death was the gangrenous phlegmasia of the scro-
tum. It is not clear that the symptoms met with in these two patients were
to be referred more to the operation in question than to any other. The most
trifling puncture has sometimes produced them, and it is not rare to see them
occur spontaneously. The accident to be apprehended in the process of M.
Belmas is peritonitis ; but this phlegmasia was not observed in the patient
who died under my care, and I do not perceive that it existed in the little
patient of M. Dupuytren. The natural conclusion to be drawn from all
this is, that in such a condition a puncture or incision would probably have
536 VEW ELEMENTS OF
produced the same fatal results, and that in reality these facts are bj no means
conclusive against the idea of M. Belmas, if in other respects it has sufficient
foundation. This last question brings us naturally to consider the absolute
and relative value of the various methods wc have already discussed.
§ 3. /s itjjossihle to obtain a permanent Cure of Hernia^ and ought it to he
attempted?
After having long believed in tlie efficacy of the thousand means succes-
sively boasted of as producing it, the profession has arrived at the conclusion
that the radical cure of hernia is almost impossible. The openings through
which the viscera escape, being surrounded with bone or fibrous bands have
not, it is said, any tendency of themselves to close; and the mind does not
in the first place perceive how the operations proposed could determine their
obliteration. Besides, what is indicated by theory has often been confirmed
by experience, for every body agrees that the operation for strangulated her-
nia does not relieve the patient from the necessity of wearing a bandage, if
he would prevent a relapse. It remains to know if in both these^-espects we
are not imposed on by prejudice. If it is true that herniotomy does not al-
ways prevent a return of the disorder, it cannot be denie4 that it does so
sometimes, and even very frequently. I could cite many examples ; among
others, that of a young student of medicine upon whom I operated in 1827;
a second more remarkable, inasmuch as it concerns a man thirty years old
affected with congenital hernia, upon whom also I operated in 1824, at the
hospital of Improvement ; and a third of an adult with an entero-epiplocele
of several years' standing, on whom Dr. Payen operated in my presence
about the beginning of 183 1 . The operation for hernia leaves a wound which
almost necessarily suppurates, and the whole extent of which must be covered
with cellular granulations as far as the ring. Hence results a new tissue ; the
base of the cicatrix, which, by its great elasticity and the adhesions which it
contracts with the surrounding parts, will certainly tend to close solidly the
hernial passage. To understand the whole action of the cicatrices in this
case, it is sufficient to call to mind the displacement caused by those usually
produced by burns, variola, &c. But to arrive at this result (he wound must
suppurate — its union must not be immediate; in a word, the whole surface of
the sac and the interior even of its neck must have time to form cellulo-vas-
cular papillae. If the art has the power of radically curing certain hernias,
the means of arriving at it is to close their passage by an inodular cicatrix.
Cauterization is evidently calculated to produce it ; for example, when it acts
on ^ whole substance of the scrotal tunics and reaches the internal face of
the neck of the sac. Ligature, mediate or immediate, offers less certainty,
because it acts only from without inwards, and under its influence the interior
of the ring may remain free from all morbid action. The loss of substance
from excision is a guaranty of success which cannot but be appreciated. Even
simple incision no doubt frequently succeeds, iT we are content to close the
wound by the second intention. Scarification must excel all other processes ;
first, because it does not expose the chord to lesion as much as cauterization,
nor tljc vessels, as excision ; and then because it is followed with a cicatrix
mttch more firm than incision strictly so called, to which it adds scarcely any
OPERATIVE SURGERY. » 537
difficulty and complication. As to Dr. Jameson's method, if new cures should
confirm what has b^en said by its inventor I would consider it preferable to
every other. The tegumentary stopper which he places in the ring, would
admirably supply the place of the strongest cicatrix, at the same time allow-
ing the im^iediate union of the wound. That of M. Bel mas would probably
do equally well if inflammation and suppuration of the whole surface of the
sac did not often complicate it, and sometimes render it dangerous. Until
experience has more amply tested the value of the two last methods, I would
accord the preference to scarifications in an attempt at a radical cure of
hernia.
As a possible result I do not think that this cure can hereafter be con-
tested. The only question is, at what price can it be obtained r In itself the
operation is in reality neither difficult nor very delicate. Injury of the tes-
ticle, the chord, the vessels, and the various local symptoms it may bring on,
are not inevitable. General symptoms and peritonitis, which have more than
once been the consequence, constitute therefore 'its principal dangers ; but
will the few cases related by J. L. Petit, Richter, Abernethy, &c., suffice to
settle this question. The removal of a cancer, the operation for congenital
hydrocele, have also caused death, and still no one concludes it necessary to
proscribe these operations, although applied to less serious disorders than her-
nia. Who will pretend to say that accidents, sometimes so serious, produced
by phlebotomy, should be a cause for rejecting bloodletting ? Is there a single
operation, even a simple puncture, which may not become fatal under more
than one combination of circumstances ? If such possibilities always stopped
the surgeon, would he ever have occasion to open a bistourj^ or empty an
abscess ? For myself, I cannot see that up to this time, observation has de-
cided on this subject witliout appeal. On the contrary, I am disposed to think
that, justly intimidated by fatal exceptions or inexplicable coincidences, mo-
dern surgeons have been biased in the examination of so important a remedy,
and that it deserves to be subjected to new trials before it should be entirely
renounced. But supposing a desire to attempt the radical cure of hernia, it must
not be supposed to be applicable to all cases without distinction. In youth it
offers less danger and greater c/iance of success. The two extremes of life
are less favorable, on account of indocility of children and the rigidity of tlie
tissues in advanced life. Old, voluminous, and irreducible hernias, compli-
cated with extensive adhesions, are generally ill -adapted to it. Nevertheless,
it may be employed wifn advantage if the enterocele and epiplocele are kept
in the bottom of the sac only by a band that may be easily divided with a
cutting instrument. It is clearly indicated, for example, when in a congeni-
tal hernia filamentous adhesions expose the testicle to painful tensions, and
to being drawn towards the ring whenever the viscera return or reduction is
attempted. The risk run by Zimmermann after this operation, was probably
owing to the difficulties experienced by the surgeon rather than to the ope-
ration itself, and is of no weight against it. In fine, herniotomy will succeed
best with adults or persons approaching the adult state in enteroceles, free
from adhesions, of small size, and of recent occurrence. When the operation
is to be performed, the patient is to be treated and placed as for removing a
strangulation, whatever in other respects be the method adopted.
68
«;
538 NEW ELEMENTS OF
§ 4. Inguinal Hernia,
Besides the preceding methods, which are applicable to it in common with
every other kind of hernia, inguinal hernia has caused the invention of a great
number of others which can only be mentioned in discussing it particularly ;
such are in particular castration, the golden stitch, and the royal suture.
1. Castration, Some advocates of excision, of the ligature or compression
of the sac, finding dissection of the peritoneal elongation too difficult, cut the
knot, by including the spermatic chord and tlie sac in the same ligature.
Hence arose castration^ To perform it, Paul directs a T incision to be made
on the anterior face of the scrotum. The transverse wound serves for apply-
ing the ligature, the other permits the extirpation of the testicle. There are
some who with Franco laid bare the genital gland at its inferior part, dissected
the chord and sac from bejow upwards, tied the whole near the ring and cut it
below the ligature. In the last century some constricted the chord and sac
separately before excising them. Others went so far as to include the chord, the
sac, and the scrotum in the same ligature. This criminal operation, practised
with a sort of mania by the old surgeons, is novv^ forbidden by our laws. To
suppress the custom in his states, Constantine was obliged to attach to it the
penalty of death. Dionis speaks of a charlatan who fed his dog with testicles
removed in this manner. In 1710, Housse v/as sent to the galleys for the
same act. Castration was performed not only to cure, but to prevent hernia.
With this idea thousands of children have been mutilated. Women them-
selves had the temerity to undertake it. M. A. Prosse was whipped in 1735
at Rheims for similar misdeeds. Since that period, in the same diocese, there
was a wretch who boasted she. had performed it on more than five hundred
subjects. Some of our provinces have been the theatre of similar scandalous
acts within a few years past. To explain hcv/ it happens that even at this
time certain beings outrage morality and the laws by practising this operation
v/ould not be very easy. I am not sure however if the fault is not as much
ith the surgeons as with the public. To do it away, gentlemen of the pro-
fession have represented castration in suth cases as excessively dangerous,
and capable of frequently producing death. On the other hand, according
to them, it never produces a permanent cure, a^d is always useless ; but there
is in these assertions an exaggeration which over^pots the mark. The atten-
tive perusal of the old authors proves that the imhvense majority of patients
who submitted to it did very well, and that many of them were thus freed of
their hernia. The mass of the community renounce these errors and their
prejudices only when clear and defined truths are offered in their stead, and
not when an attempt is made to oppose them by other errors. We must not
hope to do away castration by maintaining that it is fatal and^eldom succeeds,
but by speaking truly and showing the people that it is frequently dangerous,
that it does not always succeed, and that it deprives man of ^n important
organ, and that it may bo advantageously supplied by an operation unattended
with these inconveniences. The only cases which permit its application are
those of sarcocele and an incurable degeneration of the testicle coincident
with bubonocele. Notwithstanding what Sharp says, I do not see how adhe-
sions, whether epiploic or intestinal can require it, when at the time of celo-
tomy they prevent the reduction of the displaced viscera. At the moment
OPERATIVE SURGERY. 539
of terminating an operation of strangulated hernia, it is not sufficient that
the testicle be a little more or less in size than usual, that it appear a little
diseased, but it should be extensively altered for a surgeon worthy of the
name to decide on its removal ; and it was not without extreme surprise that
I found recorded in the most recent work of one of our great masters, two
cases of quite an opposite character.
2. Point Bore. — A process, traced as far back as Oribasius, which was in-
tended to avoid the loss of the testicle, and at the same time produce the
effects of castration, is the golden stitch. It consists in passing a gold wire
around the chord and the sac, and then applying compression in such a man-
ner that only the latter shall be constricted; and then uniting the wound
without regard to the presence of the foreign body, which the patient is to
wear during the remainder of his life. This method was used in Denmark
by Bucliwall, and in France by Berrault. It is not described precisely in
the same manner by A. Pare, who directs a wire of lead instead of gold, and
tliat it be removed after a certain period. The absurdity of such a practice
is sufficiently striking without any comment. Everyone perceives at first
sight tliat a ligature so applied cannot save the chord more than the sac, and
that it will oftener produce atrophy of the testicle than the cure of the bubo-
nocele.
3. Royal Suture. The suture called royaly because according to J. Fabri-
cius its intention is to preserve to kings useful subjects, is far from deserv-
ing the, same reproach as the point dore. To perform it, the ancients first
dissected the sac, insulated it from the surrounding tissues, and then sewed
it for its whole length v.ithout touching the chord. This appears to have been
the practice of the Turks at the period when Cantemer wrote his History of
the Ottoman Empire. But Sharp thought to improve it by proposing to sew
at the same time the sac and tiie integuments near the ring. In any way it is
seen not to require the sacrifice of the testicle, and that it must offer greater
probability of success than the golden ligature. However, as this is in reality
but the suture applied to scrotal hernia, and as scarifications have in this
place the same advantages as elsewhere, I will not dwell longer on the im-
portance of the royal suture.
Art. 2. — Strangulated Hernia.
Hernia is sometimes complicated with accidents which render it one of the
most serious disorders, and one of which operative surgery possesses the sole
remedy. Obstruction and strangulation, the most formidable of these acci-
dents, deserve for this reason all the attention of the surgeon. A hernia is
said to be obstructed when the substances destined to escape by the anus are
arrested in the intestinal fold which forms it, so as to interrupt in this place
the passage of substances whose course is through the digestive tube. Stran-
gulation is constituted by mechanical constriction exerted by the surrounding
tissues from without inwards upon a portion of the alimentary canal, so as to
efface more or less completely its calibre, and powerfully disturb its principal
functions. From this definition, it is perceived that strictly considered there
may be obstruction without strangulation, and vice versa. Nevertheless, aa
obstniction seldom becomes dangerous tut from the strangulation which soon
540 NEW ELEMENTS OF
takes place, I see no disadvantage in following the course adopted by many
authors, who consider these two accidents but as the cause and effect of each
other, and only treat of strangulation. In fact, strangulation may be brought
on by various causes without any change in its nature. It sometimes is
effected slowly, at others suddenly ; it is of various degrees, is attended or
not with inflammation, but it is not the less strangulation. The term incar-
ceration^ which Scarpa employs for cases in which the intestine is only dis-
tended in the hernia without being materially injured, seems to roe to be of
no advantage. Words are of little importance, provided they give a clear
idea of the thing. Its mechanism is of two kinds ; a fibrous opening of the
abdominal parietes may yield and dilate at a particular time from some effort
of the subject, and allow a portion of the viscera to escape, and by virtue of
its elasticity contract again so as to produce a violent constriction on the
organ just passed through. In this case there is a strangulation by reaction
of the herniary passage. In other cases the contained parts swell and be-
come distended more or less promptly, and by this eccentric movement are
not long in producing strangulation, which in this case occurs from reaction
of the incarcerated organs. The first §jenerally appearing suddenly, some-
times with the hernia, or by the addition of a new portion of viscus in the
containing sac, being rapidly followed by inflammationj has received the
name of acute or inflammatory strangulation. The second being developed
only by degrees, except in hernias, which are not habitually reduced, exciting
inflammation only after considerable lapse of time, constitutes the slow stran-
gulation, or strangulation from obstruction ; which, liowever, does not abso-
lutely prevent its being manifested at times with great suddenness. It is
sufficient to remark that the openings through which hernias are produced are
entirely fibrous, and consequently deprived of any contractile property to
show that spasmodic strangulation imagined by Richter and some others is
really impossible. Fages of Montpelier, who, according to M. Delmas, con-
tinued to admit it, attempted in justification of his opinion to transfer this
pretended spasm to the large muscles of the abdomen, which would then
react on the hernia by giving more rigidity and tension to the aponeurotic
bands. But in the mind of any one who understands the anatomy of the
abdomen, such an idea refutes itself, and does not require to be opposed.
However this may be, strangulation may act on various organs and have its
seat in very different places, a circumstance not well understood, and from
which no advantage can be drawn in the treatment unless we remember
exactly the composition of hernias.
§ 1. Anatomical Remarks,
Every hernia offers two things for consideration, its envelopes and the vis-
cera which constitute it.
1. Viscera. There is no organ within the abdomen which may not possibly
form a hernia ; all, however, are not equally likely to strangulation. Thus
the bladder, the ovaries, the uterus, the spleen, and the liver have been seen
together or separately in a hernial tumor. But with the exception of the
urinary reservoir, it can scarcely be conceived how these various organs are
liable to strangulation. The intestine, a large canal continually giving pas-
OPERATIVE SURGERY. 54 1
sage to abundance of substances, must on the contrary when its calibre is
effaced, when it becomes impermeable in some point of its length, disturb the
whole economy and give rise to numerous distressing symptoms. A constric-
tion of the epiploon it is true does not explain so well these phenomena ;^, but
whether it depends on tractions exercised upon the stomach and large intes-
tine, or on a sympathetic reaction transmitted by the trisplanchnic nerve, expe-
rience proves that they may then be manifested and they must be admitted.
In order not to confound these parts with each other it is important never to
forget their principal characteristics. The spleen, blacker, softer, and more
easily torn if its membrane is broken, than the liver, may be distinguished from
it besides by the yellowish tint and granulated appearance of the latter.
The small intestine differs from the large in its size and the regularity of its
external face. Its fullness and the absence of folds and muscular bands in the
stomach do not allow it to be confounded with the one or the other. The
fatty appendices of the colon differ too much from the spreading form of the
epiploon, to be mistaken. As for the epiploon itself, as it may lose its membrani-
form condition, after remaining some time out of the abdomen, and the adi-
pose flakes which are often found on the external face of the peritoneum, and
sometimes acquire sufficient size to simulate hernia, may, if we be not on our
guard, lead unto error on this point. However, unless there are morbid ad-
hesions the embarrassment of the practitioner will not last long, if he call to
mind that the omentum is prolonged into the belly while the purely adipose
lumps have their origin without that cavity. The blood vessels of each organ
have here some interest. In the intestine they form arches, arborizations,
and fern-leaf expansions in the bladder, and also in the coecum simple diver-
gent arborizations without very evident arches. Those of the peritoneum and
its cellular lining spread into stars by layers and in a very irregular manner.
In the epiploon their volume is enormous in comparison to the thickness of
the lamellae through which they pass, and at a certain distance apart they are
observed following a direction parallel with each other. In the mesentery,
certain venous branches sometimes increase so much in size as to occasion
serious hemorrhage if they happen to be opened, a remarkable example of
which is related by Scarpa; but we shall have to return to this subject here-
after.
2. Envelopes, — The envelopes of every hernia contain, as essential elements,
the integuments, the peritoneal sac, and the intermediate layers. The skin
presents nothing remarkable, except in regard to varietes of thickness, den-
sity, and adhesions. With the sac it is quite otherwise.
a. Sac. — .The name of sac is given to that portion of the peritoneum drawn
by the viscera out of the abdomen, and which forms the most immediate
covering of the hernia. The older writers had only confused ideas on this
subject. They imagined that descents or hargnes (hernias), which they also
called for this reason ruptures or breaks, took place through a rent in the peri
toneum. At the time of Dionis it is true the case was otherwise, and the exist-
ence of the hernial sac was admitted in the majority of cases, at least it was
not rejected, except in certain special hernias, the umbilical for example ; but
it is only since Mauchart and Arnaud, since the middle of the last century,
since the academy of surgery, that it has been regarded as an essential part
ot every kind of hernia; so that its presence is now universally admitted. I
542 NEW ELEMENTS OF
mistake, the moderns agree that hernias, in consequence of penetrating wounds
of the abdomen, the Cassarian operation, ligature of the iliac arteries, and gas-
trotomy, are usually without it. When the bladder is displaced in its anterior
face, or the ccEcum in its adherent face, there is no hernial sac. This is a
fact quite recently demonstrated by Mr. Calson in opposition to Scarpa, who
has gone to a great length to prove the contrary. Let us remark however,
under this last point of view, that it is more a dispute about words than a real
dift'erence of opinion. In maintaining that coecal and vesical hernias have a
sac, Scarpa only meant that a greater or less portion of the displaced organ is
free within the tumor, and that there is found there a prolongation of the peri-
toneum as in ordinary hernia. Mr. Colson does not think of denying this
disposition ; he only contends, that the hernia being adherent by the greater
part of its surface the name of sac cannot be given to that portion of perito-
neum that covers the rest. Some again believe that hernias caused by trau-
matic lesions of the abdomen have a sac like the others unless they occur
before the complete cicatrization of the wound of the peritoneum. This is a
question which appears not to have been presented in its proper light.
When a penetrating wound is closed and healed, there ordinarily results a cica-
trix less thick and less firm than the natural parietes of the abdomen. This is
explained not by saying that the two lips of the wound of the peritoneum are not
united, but that instead of muscle and aponeurosis there is in this place but a
fibro-celkrlar tissue of new formation. If therefore a hernia is formed through
it, whether it push the cicatrix before it or m.erely displaces by passing through
it, it is not perceived how it can fail of being surrounded on all sides with peri-
toneum, and of thus having a real sac. But this cicatrix may in some mea-
sure remain independent of the serous abdominal layer, as it is possible that
the peritoneum may be so adherent to the margin of the opening which
gives passage to the viscera, that the hernia shall receive no sac from it.
What takes place in this case is also observed at tlie umbilicus. I am possi-
tively assured from dissection that in general exomphalos has no internal tunic
which may be separated from the other envelopes. The smooth layer that has
been taken for it is intimately connected with the external tissues, and is de-
veloped by dilatation like that formed in cyst, usually filled with diaphanous
or synovial fluid, and not by displacement or elongation of the peritoneum.
These remarks bring me to admit, 1st, a true sac, or sac by transfer of the
peritoneum; 2d, a false sac from simple distention of this membrane, or any
other form of cellular tissue; 3d, an incomplete sac for vesical and coecal
hernias, &c., that is to say, that the hernial pouch is covered entirely with a
true serous membrane in the immense majority of cases, only partially in some
others, and in the smallest number of cases a simple surface instead of a mem-
brane is seen (3n its interior; as for instance, the uterine cavity presents but
a mucous surface, while in the intestines there is a real membrane o{ ihh name.
The/orm and volume of the sac vary almost infinitely. Henuspherical,
globular, pyriform, irregular, conical, cylindrical, wallet-shaped, with a double,
triple, or guadruple neck, &c. — it may scarcely be larger than a hazel nut, or
equal in size the head of an adult. Its internal face is polislied and humid,
and does not differ from that of serous membranes in general. Its external
face demands a little more attention. In the true sac it is lined v/ith a cellu-
lar layer which pliiys an ixportant part in the hi^^tory of hernia. Thia kycr
I
OPERATIVE SURGERY. 543
is a portion of wiiat I willingly call fascia superjicialis interna, or the fascia
propria of the peritoneum, and exists throughout, but with various degrees of
laxity, thickness, and adhesions, over the different points of the abdominal
cavity. It is this through which run the blood vessels generally attributed to
the peritoneum, and which by its induration and gradual condensation pro-
duces, what is called the thickening of the sac; and whicli having undergone
a filamentous or semifibrous transformation gives origin to that knotty appear-
ance and those inequalities on the external face of certain hernias, and which
may also be the seat of inflammation, suppuration, and morbid alterations of
every kind. It is from this also that most of the vessels come which terminate
beneath the skin after passing through the muscles and aponeurosis, and that
those small adipose masses arise which, passing little by little the vascular
orifices of the fibrous and muscular layer and abdominal parietes, in the end
sometimes make a projection beneath the skin, and are mistaken for real her-
nias. Around the false sac this layer intimately blended with the surrounding
lamellae, distinguishes it from the preceding, and makes instead o^ 2i separable
membrane, a surface incapable of any motion; so that no adipose lumps,
morbid deposits, nor infiltration of fluids can possibly be between it and the
rest of the herniary coverings.
The name of neck, which is given to that portion of the sac which remains
in the herniary opening, might be advantageously superseded by that o^ root ;
for the first brings with it the idea of strangulation, which is far from always
existing, while the second, which is equivalent to the word origin, will express
exactly the object in every case. However, as in operative surgery particu-
larly the use of it can do no harm, I will continue to employ it. The neck
of the sac there, and I mean of the true sac, is ordinarily narrower than the
body and fundus of this pouch, and often puckered like a purse in the ring
that contains it. If the hernia is of long standing, if they remain long in
contact, it is easily conceived how these folds may agglutinate and give to the
neck in question a considerable thickness and power of resistance, which in
fact is very frequently observed. The presence of several necks in a single
hernia, so well explained by Arnaud, and since by Pelletan and Scarpa, has
nothing in it obscure or surprising to any one since the appearance of the
works of M. J. Cloquet. If after having been long reduced a hernia should
suddenly reappear, the neck of the first sack beiug too narrow to allow pas-
sage to the viscera v/ould be pushed forward by them, at the same time that
they carried along a new portion of peritoneum, and form a new neck. If
the same thing happen a second, a third, and a fourth time, we shall have a
sac with several necks. AVhen the first adheres powerfully by a part of its
body to the neighboring tissues, it is possible tliat the other only gives it a
valve-like motion instead of making it descend directly before it. In this
zaallet the two pouches are in front or at one side, and not one below the
other. The production of these necks is still possible without the hernia
having returned. Then it is a new descent which forms above the old one.
The adhesion of a chord or epiploic mass to the bottom of the primitive sac
is most particularly favorable to the formation of a second neck. Pelletan
cites a case in which the epiploon traversed in this way three contractions and
fixed itself at the bottom of the lowest sac. I have seen one quite similar,
another in which the superior sac enclosed also a coil of intestine, and yes-
544 NEW ELEMENTS OF
terday at La Pi tie, one which hardly differed from the first. As to the
numerous necks of knotted sacs they are formed in quite another manner.
These are simple hernias of the sac between the fibres of the fascia propria,
or of any fibrous layer that may have taken its place. Instead of necks, the
sac may be divided by real septa, and form one or more independent cysts
below the portion which continues to enclose the viscera. The patient ope-
rated on after the manner of M. Belmas offered me a beautiful example.
b. ^Aponeuroses, — The tissues which separate the sac from the cutaneous
covering necessarily vary with the seat of the hernia, and cannot be usefully
studied but on occasions of each hernia in particular. I consequently shall
only for the moment attend to the common cellular tissue — the fascia superji-
cialis. When there are neither aponeuroses nor muscles interposed, the/«sc{a
propria and the fascia superficialis are finally blended in the thickness of the
herniary pouch; that is, no separation between the cellular lining of the skin
and that of the peritoneum is distinguished. Yet as, in its deepest part, it is
lamellar, and not filamentous nor adipose as in approaching the dermis, it
sometimes assumes the appearances of an aponeurosis which prevents this
confusion. It is the seat of the subcutaneous veins and ganglions, and of
the infiltrations, suppurations, and indurations which are consequent upon
acute or chronic inflammation, and may grow to a surprising thickness even
after allowing for the fat naturally found in it, and thus remove the hernia
considerably from the exterior of the body.
b. Herniary Openings — .The openings which permit the formation of ab-
dominal hernias are of several kinds. Some being accidental frayings, such
as happen to individuals whose abdomens have been violently distended by
pregnancy, ascites, a tumor of any sort, &c., very rarely give place to stran-
gulation. The same remark applies in great measure to those resulting from
penetrating wounds of the abdomen. There are others which are also not
worth a long discussion. The orifices which are found here and there in the
several fibrous layers of the oblique or transverse muscles for the passage of
vessels of the third order are of this description, and offer besides this re-
markable fact, that the masses or fatty tumors, the pedicle of which they sur-
round, which enlarge beneath the skin, and adhere besides to the peritoneum,
may dilate them and drag through by degrees a portion of that membrane in
the form of a sac or the finger of a glove, in which the intestine may in turn
be lodged and even stratigulated, and constitute a species of hernia very em-
barrassing to a practitioner who had had no previous notion of it. Those of
which it remains for us to speak, may be referred to two orders : these are
simple openings which are called rings; and passages of greater or less
length, more or less oblique, and generally known at present under the name
of canals. At the umbilicus, for example, the opening is always a ring, while
at the bend of the groin it is always a canal.
Rings. — The first species is only met with on the points of the abdomen
where the aponeuroses and the muscles do not form distinct layers, as for
instance at the linea alba, or the flank, the vagina, the rectum, &c. These
parts being in fact not separable into laminae, but only opened to allow the
passage of the viscera, the hernia arrives under the skin immediately after
passing through them, and has only to pass through a mere circle to become
formed.
OPERATIVE SURGERY. 545
Canals. — The second is more complicated. Its entrance and termination
represent two distinct circles, two rings sometimes at quite a considerable
distance apart. It can only occur where the several layers of the abdominal
parietes are commonly separable. Vascular, nervous, or other chords occupy
it in its normal state. Its passage may be said to have parietes, and depends on
muscles or other tissues keeping its two orifices more or less apart, and on its
two rings belonging to difterent aponeuroses. If its entrance and exit are
exactly opposite to each other the canal is straight or perpendicular, on the
contrary it is oblique when they are situated at unequal distances from tlie
median line, which is more frequently the case. Let us add, however, that
when of long standing hernias tend to efface the obliquity and the length of
their passages and to transform them into simple rings ; and this by a mechan-
ism easy to be explained. Pressed in inverse directions by the portion of the
organ that has come through and by that which tends to escape, the deep
seated and superficial aponeuroses gradually diminish the interspace which
naturally separates them, and finally come in contact. Taken in its whole, an
oblique hernial canal represents pretty much the shape of a Z elongated. But
it is evident, that the viscera occupying such a canal, would from their own
gravity continually tend to straighten it to bring its openings opposite to each
other; and that then, as in the preceding case, they might reduce it to the state
of a ring almost perpendicular. But whether it be circle or canal, the hernial
opening is almost constantly widened into a funnel at the abdominal ex-
tremity, in some persons more than in others. As, on the other hand, the
bloodvessels which border on the neck of the hernia, commonly run in the
substance of i\\e fascia propria, that is, between the peritoneum and the deep-
seated aponeuroses, it results that they are generally found removed from two
to three lines at least from the fibrous edge which causes the strangulation,
or upon which we are obliged to use the bistoury to effect a relaxation.
§ 2. Seat of Strangulation,
Although it is commonly at the neck that hernias are strangulated, it also
sometimes takes place in their body. In this case the strangulation is pro-
duced either by a rupture of the sac which has allowed the organs to escape
into the surrounding tissues through an incomplete partition, a contraction, or
the orifice of a lateral cell of this envelope, whether from an abnormal disposi-
tion of the displaced viscera, or from bands or morbid tumors. The twisting of
the intestinal loop upon itself, for example, may produce it ; and so may an epi-
ploic band, which may pass in front of the intestine as if to divide it into two
portions, before fixing itself at the fundus of the rupture ; and also an opening
torn in this membrane in the middle of the sac, through which part of the
intestine shall have passed. The epiploon may also be rolled into- a cord,
and fix itself first to one side, then to the other, so as to form a kind of bridge,
and even a second one by attaching itself again to the first wall of the hernial
cavity. Two of its prolongations sometime approximate after contracting
adhesions laterally, and unite a little low'er down ; leaving between them a space
which is also apt to cause strangulation. All kinds of bands may do the
same as the epiploon. Hey gives a drawing of one, which fixed by its extre-
mities to the two sides of the sac formed a complete circle in the middle
69
546 NEW ELEMENTS OF
through which the intestine passed. A hard epiploic mass, of the size of a
large hen's eg^, had produced strangulation in a patient whose body I had an
opportunity to examine. An enormous tumor of the mesentery had produced
the same result in a man operated upon by Pelletan. The, appendix of the
coecum would also produce it, if it should get into the hernia and adhere at its
point. It is the same with the thousand pathological alterations capable of
compressing the digestive tube and interrupting the course of its contents.
Even inflammation of the sac, caused by external violence, may bring on stran-
gulation, as is proved by the case of a patient published in tlie Strasburgh
collection of theses (1803), who had received a spent ball upon the scrotum.
At its root the hernia may be strangulated at first in the manner just described,
and afterwards by the opening through which it necessarily escapes. But
this opening we now know includes several objects, the constricted portion of
the peritoneal elongation, and the circle Or fibrous canal which contains it.
At first view it appears difficult for the neck of the sac to produce strangula-
tion of itself. Nothing however is more common ; the adhesion of its folds to
each other very much increases its thickness. Cellular lamellae are then
successively Applied to its external face. The plastic lymph deposited there,
at the same time unites the whole, and insensibly gives to the part great den-
sity, and a thickness which may become considerable ; for Arnaud says that
it was more than half an inch in one of his patients, and M. Graefe has
noticed the same fact. A lardaceous and even semi-cartilaginous appear-
ance is also manifested there in certain cases ; in such a w ay, that being
arrested from without by the assistance of the ring, the thickening is affected
at the expense of its own calibre by a concentric reaction, the whole force of
which bears upon the intestine. Strangulation therefore is sometimes so far
independent of the opening in the abdominal parietes, that this remains en-
tirely free, and sufficiently large to allow an easy movement to the neck of the
sac, so that we may succeed without difficulty in making it repass into the abdo-
men without diminishing the constriction at all, if it has not been previously
incised. Arnaud, Le Dran, &c., were the first to insist on this disposition,
of which Riviere, Schenck, Littre, and Nuck had given but an imperfect
glimpse, and the knowledge of which has been made general by Scarpa, after
Pott, Wilmer, Hey, and Sandifort. In France, M. Dupuytren is one of those
who have most frequently met with it, and pointed it out with the greatest
emphasis. Mr. Lawrence, who at first refused to believe in it, admits its
existence in the last edition of his works ; and at present this mode of stran-
gulation is no longer called in question. It presents even several distinct
gradations, may be altogether annular, very circumscribed for example, and
occupying but the entrance, the termination, or the middle part of the neck, or
invading the whole of this prolongation, and transforming it into a kind of case
or sheath more or less compact. The aponeurotiq opening, the part to which the
strangulation was formerly almost exclusively attributed, also produces it in
a considerable number of cases. But since the difference has been acknow-
ledged between the simple ring and the hernial canal, a distinction as to the
neck of the sac has become indispensable ; that is, in openings in form of a
canal, so far from being always situated at the external orifice as was supposed,
it is equally developed at the internal orifice, on an intermediate point, and
sometimes on these several parts at once.
OPERATIVE SURGERY. 547
The most difficult, and at the same time the most important point in stran-
gulation, is to distinguish it clearly from every other affection. If the tumor
is small and had not fixed the attention of the patient, a too superficial ex-
amination may lead to the belief of the existence of a violent phlegmasia, of
volvalus, poisoning, &c. These mistakes are by no means rare, even when
the hernia is not very small. Some days since a surgeon in the neighborhood
of Paris, was called to a patient whom he thought aft'ected with gastritis, and
treated accordingly. The symptoms continued. A second surgeon was
called in who found it strangulated hernia ! A domestic of a dignitary of
state died last year of what was considered intestinal inflammation ; after
death it was discovered to be strangulated hernia ! A strong and hearty man
was seized with violent colics, and convulsive motions ; it was thought to be
gastritis. Leeches to the epigastrium, &c., were ordered for three days. He
was carried to La Pitie. He had a bubonocele which I was able to reduce
forthwith. A little more knowledge or precaution in such cases would easily
prevent error, though not always, for the most skillful are sometimes mistaken.
In 1817 a woman, directress of the infirmary in the hospital of Tours, was
seized in the night with colic, vomiting, &c. I questioned her; she had
never had a rupture. The next day M. Bretonneau examined her; there
was no sign of tumor in the abdomen or the groins. However, pain was in-
creased by pressure in the hollow of the thighs, and from this spot the colic
seemed to arise. A strangulation was suspected, but what was to be done ?
Death took place the following night. A portion of intestine of the size of
a walnut was strangulated in the left crural ring, and made no prominence
externally.
Peritonitis. — A number of circumstances may be mistaken for stricture of
the intestine in persons affected with hernia — peritonitis, for example, when it
is accompanied with constipation and vomiting. L^pon the advice of two gen-
tlemen in consultation, and against his own opinion, Pott operated upon a
young man whose hernia seemed to be strangulated. There was no lesion in
the tumor. The patient died, but it was of intense peritonitis. Being called
to another case. Pott would not operate. The death of the patient allowed
him to establish that the hernia was not strangulated, and that inflammation
of the peritoneum had caused all the symptoms. Mr. Earle was no less unfor-
tunate in 1828. The operation proved that an enteritis had led him into
error, and that no strangulation existed. Let us observe however that in this
case the disease is generally ushered in by a chill more or less violent, that
the pains are much more acute in the belly than in the tumor, that the vomit-
ings are glairy, greenish, and not stercoraceous, and that the face tends to
shrink, but not to become hippocratic.
Inflamed Sac. — A no less difficult case is the following : the sac of an irre-
ducible hernia, or the intestine which forms it may become inflamed, hence
all the signs of acute strangulation. Hernia* without adhesionfe are liable to
the same accident. Sometimes however the ring remains free, and in no
manner compresses the organs passing through it. To suspect this condition
the pain must have commenced at the body or the base, and not at the root
of the tumor ; the skin itself must have partaken of the inflammation from
the begini:ir.gj and it must be possible to feel with ihe ^*ger the laxity of ,i^e
548 NEW ELEMENTS OF
hernial openings. This is in fact sometimes the case. But when the hernia
is not of any considerable size, how al*e we to profit from these circumstances ?
Happily in this case, as in real strangulation, the operation is the best remedy
to be employed. The viscera have been reduced — the tumor reappears —
symptoms of strangulation manifest themselves. The operation is performed,
and the surgeon finds only a pouch full of fluid, either purulent Or fiocculent,
serous or sanious. This pouch is the inflamed sac, the orifice of which has
been closed by the inflammation. Numerous cases of it have been reported
latterly by MM. Dupuytren, Duparcque, Sanson, and Janson. Mr. Key
has also been deceived, and the error could not be avoided if it were not that
it is almost always possible to procure some stools, or that the stercoraceous
vomitings do not take place as in real hernia.
Certain Hydatoid Tumors m'dj be ranked in the same class, as appears from
a case recently published by M. Pigeotte of Troyes, and from those given by
Desault, Dupuytren, and M. Roux. A simple imposthumated lymphatic
tumor, an indolent abscess, and a common abscess enter with equal propriety
into this list. M. Baud of Lou vain, thinking to operate for strangulated
hernia found only a lymphatic tumor, the pedicle of which he tied. The
symptoms were aggravated, the patient sunk ; and it appeared from the au-
topsis, that the thread applied round the elongation of the morbid gland, con-
tained a portion of intestine. The same mistakes may arise from tumors
purely fatty, and have b.een caused by them more than once. Suspecting a
strangulation, Scarpa laid bare the supposed hernia, and found only a pedun-
culous adipose mass, which he excised. After running great risk, the woman
in the end recovered. M. Cruveilhier cites a case in which the operator, less
fortunate, lost his patient. A woman in the ward of M. Parent at La Pitie,
was seized with colics, vomiting, constipation, &c. She had an old tumor at
the umbilicus. Being called to her, I observed all the symptoms of strangu-
lated hernia and threatened peritonitis. Before proceeding to the operation,
I thought proper to prescribe a bath, leeches, cataplasms over the abdomen,
and enemata of various kinds. They forgot to transfer her to my ward, and
death took place on the third d^^y. There existed an intense peritonitis
having its point of departure on an old lesion of the sexual organs, and the
supposed hernia was nothing more than a pcdunculous fatty tumor. An
epiploic lump may be transformed into ^ hydatid, or a hard and immovable
tumor, become inflamed, form abscess, and be no less embarrassing, especially
it an intestinal loop exist simultaneously in the hernia. A reaper was, sud-
denly seized with colic and nausea, and at the same time perceived that a
tumor as large as his fist had descended into the scrotum. He Avas admitted
at La Pitie on the seventh day. The hernia was formed of two portions ;
the superior, soft and not very sensible, which I succeeded in reducing ; the
other very hard and larger, which it was impossible to return. The symp-
toms, without being very alarming at first, continued for three weeks, and
became so aggravated that the patient was on the brink of the grave, when a
purulent discharge froni his tumor put an end to his sufferings and restored
him to health. In the cliivical observations of Pelletan is a case very nearly
similar. The epiploon may also occasion error in another way. A patient
iiffected with abdominal hernia died with symptoms of strangulation. The
OPERATIVE SURGERY. 549
necropsis showed that the epiploon, although scarcely diseased without, was
violently inflamed in the interior of the abdomen, where it formed a kind of
hollow cone, of which the base embraced a preparation of the stomach.
Internal Strangulations. — Another species of disease much more capable of
leading into error, are the various kinds of internal strangulation, or obstacles
to the passage of substances through the alimentary canal, in persons who are
at the same time affected with hernia. A woman forty-two years old, who for
eight years had been affected with omphalocele, came to the hospital of the
Faculty in the month of March 1824 with symptoms of strangulation, and
would have been subjected to the operation if it had not been discovered that
she had in the right iliac fossa a deep-seated tumor, hard and very painful.
This tumor opened externally and was emptied ; a stercoraceous mass con-
tained in the coecum constituted it, and had evidently caused the constipation,
vomitings, &c. Another woman, forty-nine years old, received in the same
hospital in July 1825, vomited continually for twenty-four hours without its
being possible to obtain a stool. The abdomen was tympanitic and exceed-
ingly painful, the pulse small, hard, infrequent, &c. There existed at the
same time a crural hernia. On opening the body I found the commence-
ment of the rectum transformed into a lardaceous tissue and completely
closed. The merocele had not suffered at all. Every tumor, polypus, fibrous
or cancerous, originating in the intestine, will necessarily produce the same
consequences if it acquire a considerable size. A man about sixty years old,
a great eater, who had remained a long time in the hospital of Tours for
vomitings and a constipation which nothing could overcome, at length died.
The small intestine, largely dilated above, was closed about its middle by a
cylindrical mass more than a foot long, and about two and a half inches in
diameter, partly free and partly adherent, the result of an old degenerated
invagination. If the hernia with which this man. had been formerly affected
had still existed, the symptoms observed during life- might have been attri-
buted to it, and as the result shows altogether improperly. Similar cases are
found in numbers in the-scientific compilation. A patient who was sent to me
from the ward of M* Andral in October 1831, furnished me with one of the
most remarkable. The memoir of Hevin, which contains them all, proves at
the same time that the different gradations of invagination have often resulted
in the same train of symptoms. It may also happen tliat these symptoms de-
pend on a spiral twisting of a loop of tlie small intestine upon the mesentery,
or on its flattening against the spine, of which the death of Chopart affords a
proof; or a circular stricture of one part of the organ reduced after having
been long engaged in a hernial opening, as in the case reported by Ritsch ; or
the neck of the sac being pushed into the abdomen with the hernia, as is seen
in the observations of Le Dran, Arnaud, &c. ; more frequently still on the diges-
tive tube being engaged, to the point of strangulation, in some slits, or under
some bands or appendices of the abdominal organs. Thus M. Berard has seen
it enter the anterior mediastinum by separating the xiphoid fibres of the dia-
phragm ; it has often passed into either pectoral cavity through the body of
ihe diaphragm itself ; through a slit in the epiploon as we find in Arnaud ; of ,.
the mesentery as Saucerotte afiirms ; through the foramen of Winslow, and an
opening in the transverse mesecolon as observed by M. Blandin ; between the
bladder and the pubis, where an epiploic band fixed in an inguinal sac kept it
550 NEW ELEMENTS OF
strangulated under the caecal appendix attached by its point to some point or
other of the abdominal cavity ; under an accidental curvature of the intestine ;
an epiploic arch attached on the one part to the spine, and on the other upon
the superior strait of the pelvis, as seen by M. Bonnet in the body of a patient
who died at the hospital St. Antoine ; under an enormous band in the form of
a T, the horizontal branch of which extended from the liver to the left flank,^
and the vertical portion to the right iliac fossa; in fine, under the thousand
varieties of bands and chords which disease or accident may produce in the
interior of the abdomen. The strangulation produced by these numerous causes,
after all only differing from herniary strangulation in having its seat in the
interior of the splanchnic cavity, may easily induce error in subjects who have
also a visible external rupture. They are to be distinguished however in the
majority of cases, by remarking the point of departure of the pains and their
course ; by comparing the condition of the tumor with the condition of the
abdomen and vice versa. When it exists alone there is hardly ever a mistake,
but we are then to specify its kind, and see if art can afford a remedy. This is
a question that cannot be discussed at present, but will find a place in a
subsequent article.
§ 3. Indications,
It must be seen by what has been said that strangulated hernia is an extremely
serious disorder, and one which without the assistance of art will almost
constantly prove fatal. When once recognized, therefore, it is important to
remove it to apply a remedy. To obtain its reduction or relieve the strangu-
lation is the end to be attained. To say with Richter and Callisen, that it is
first necessary to combat the inflammatory tendency, the pain, &c., in order to
diminish the constriction of the parts, would be to take the. effect for the cause,
and attack the consequences instead of destroying their origin. To arrive at
this, the operation is not the only means which the surgeon may employ. It
is but a last resource. Before attempting it, the taxis, hlood-leiting, baths,
clysters, opiates, and various topical applications may or should be tried.
1. Taxis, — The first idea that presents itself when a. patient is seized with
strangulated hernia, is to attempt to return it into the abdomen, and in truth
this is the usual commencement. To perform the taxis, the patient is laid
so that the muscles may be easily relaxed, commencing, as Sourdiere has well
shown, with the sterno-mastoid muscles; not as is generally supposed that
this position favors the reduction by permitting the aponeurotic openings to
yield and enlarge, but because the contrary position favors much more the
expulsion than the return of the viscera, lessens rather then enlarges the ab-
dominal cavity. He is then to make no effort, no movement, but to remain
perfectly relaxed. The surgeon placed on the rights grasps the tumor with
one hand, draws it a little towards him so as to disengage it from the ring,
seizes it at the neck with the first two or three fingers of the other hand, then
pushes it up in small portions, commencing with those which have last
escaped, and directing them in the axis of the herniary opening. As soon as
one portion is reduced, the fingers of the second hand retain it and prevent
its return, while the right endeavors to reduce another portion, and so on
until a .nass remains small enough to be retumed at once under the influence
OPERATIVE SURGERY. 551
of proper pressure. When the reduction takes place freely, this last portion,
pushed by the extremities of the five fingers of the first hand, passes through
without stopping, and gives out a characteristic sound called gargouillement,
a sound which is caused by the fluid heretofore imprisoned in the displaced
intestinal loop, quickly leaving it to restore an equilibrium in the whole canal.
Epiplocele, which is besides distinguished by its uneven, rugged form, by its
soft, clammy consistence, produces no gargouillement, and does not yield with
as much facility as enterocele. The taxis should be performed according to
the same rules in both cases, that pressure may be carried much farther in the
second than in the first without inconvenience. When after some time a
portion of the hernia disappears suddenly and with noise, while tlie remain--
der rests stationary in the sac, it may be concluded that there has been
entero-epiplocele, and that it is the intestine that is reduced. It is propA'
however not to forget that enterocele strangulated by obstruction, may easily
be mistaken for epiplocele, and that its reduction is not always accompanied
with a sound of gargouillement. If the tumor is small, the fingers of the
left hand may be employed to support its circumference, while those of the
right press upon it in every direction. Even when it is of a considerable
size we may endeavor to restore it en masse if the strangulation is not very
decided, and if the hernia has passed through a simple ring. We may also,
when it is very large, grasp it with both hands and compress its whole surface
at once, as for emptying a bladder full of fluid. The gas and semi-fluid
matter thus compressed, sometimes re-enter the abdomen so as to remove the
strangulation, or singularly facilitate the after reduction of the viscera. This
process has succeeded with me a number of times. Moreover, after vainly
trying one mode we should attempt another, and the taxis is, after all, an
operation which practice and the anatomical knowledge and intellectual
resources of every one teach better how to perform, than all the details found
in the best authors. To repeat; put the parietes of the abdomen in a state
of relaxation ; support the neck of the tumor with one hand while pushing it
back with the other, so as not to let it bend over the edges of the ring instead
of going through it; disengage it a little, lengthen it, knead it in a manner so
as to spread its contents over as great a surface as possible; grasp it largely
with the hands or the ends of the fingers, as its size may admit; have it
grasped even by the hands of an assistant if very large, while the surgeon
himself holds the root; urge it back by the same passage through which it
has issued ; suspend the efforts and resume them shortly after ; vary their
direction and energy ; use them to the best advantage, but be cautious of car-
rying them 80 far as to create danger; these are the only rules the operator
requires in performing the taxis. I will add that in large hernias, particu-
larly the epiploic or obstructed it is often useful to continue the taxis by means
of a methodical compression, until it can be resumed with the hand, when it
has not completely succeeded at first. In 1825, a man forty-seven years old,
affected with an enormous entero-epiplocele, was admitted into the hospital of
Improvement. Attempts at reduction frequently repeated on the evening of
his entrance, and the next day were attended with no success; but as there
was no sign of inflammation, and the symptoms made slow progress, it was
decided to wait. The second day the action of the hand was again attempted,
and the intestine was in part reduced. To prevent its return, I forced the
552 NEW ELEMENTS OF
whole tumor in a suspensory bandage furnished with compresses. I thus suc-
ceeded in exerting an exact and considerable pressure upon it, which reduced
it one half in the course of the night, so that the taxis then succeeded without
difficulty.
The smoothing iron, the piece of lead, and the bladder filled with mercury,
applied as weights upon the hernia, in which Wilmer and some other English
surgeons say they find so much to recommend, are in reality but compressing
means, of which an appropriate bandage will always advantageously supply
the place. If the taxis has the advantage of often rendering a serious and
painful operation unnecessary, it is itself far from being entirely unattended
with danger. The viscera in which the circulation is badly conducted, irri-
tated by the constriction, and already more or less inflamed, must become
still more violently inflamed under this pressure. It is well known that
unless we proceed with all possible care, it will be very easy to contuse them,
to bring on mortification, or tear them and expose the patient to the greatest
danger. Thus for a long time it has been remarked that the operation was so
much the less likely to succeed as the attempts at reduction had been more
numerous. There are some persons, says Petit, who will succeed at any cost,
and boast of reducing every hernia; they compress, bruise, and inflame the
intestine, and it is always with repugnance that I perform the operation on
patients who have undergone such trials. Pott directs that we should not
wait longer than two hours. After he had formed a custom of acting with
this promptness, nearly all his patients got well. Previously he had lost half.
Comparative trials made at Hotel Dieu, had proved to him that the proportion
of success after celotomy was considerably gi'eater in patients operated upon
without having been fatigued by the taxis than in others. At the hospital of
Orleans, where the operation was performed from the first, Leblanc was
rarely unsuccessful ; while at Paris, where it was left until very late, most of
the subjects died. It was for this reason that Richter attempted to proscribe
the taxis. He declares that he has rarely seen a hernia really strangulated
reduced by this means, and contends that those which have yielded to it
would have gone back of themselves a few hours later. These apprehensions,
a little exaggerated, are only well founded in the cases of enterocele and in-
flammatory strangulation. The attempts must have been very awkwardly
prolonged to cause the suppuration of the epiploon noticed by Arnaud, and
immediate gangrene of the enterocele from obstruction, &c.; but it is readily
conceived that in acute strangulation the taxis if unsuccessful may become
dangerous, and render the operation infinitely more formidable than if it had
been but feebly exercised. However, in abandoning it too early we are liable
to perform a grave operation without necessity. Sometimes by renewing our
attempts, twice, thrice, or even six times, we succeed in reducing a painful
hernia which had resisted all previous endeavors. In other cases attempts no
less numerous, although unsuccessful, have not prevented herniotomy, per-
formed after the lapse of two or three days, from succeeding completely. In
fine, a strangulated hernia has been seen so frequently reduced by one surgeon
after having been vainly attempted by another, that it is difficult not to hesi-
tate when it is proposed to abandon the taxis. A porter next door to me had
an old hernia which was strangulated in the morning, only in consequence of
a single effort, and notwithstanding his bandage. During the day there were
OPERATIVE SURGERY. 55S
three failures in the attempt to reduce it. I saw him at eight o'clock at night.
His suiFering and agitation were extreme. He could not be touched without
uttering piercing cries. The whole pain was in the tumor, which seemed
unable to bear the least pressure. I would not hazard an operation however
before trying the taxis again. I obtained nothing at first but a quick and in-
voluntary-motion in the patient, while a second effort returned the whole of
the intestine. The symptoms disappeared immediately, and the next day this
man was able to resume his ordinary occupations. In the month of March
1825, M. Demay requested me to see with him at the barriere de Sevres, a
woman who had been laboring under a strangulated merocele for thirty-six
hours. The tumor was of the size of a small egg, very hard, painful, and
evidently formed by the intestines. After subjecting it to the taxis, I thought
that it had considerably diminished and would not operate. I returned there
the next day, and attempted the reduction with no more success than before.
However, as I found it in the end less in size, I persisted, and the operation
was deferred a second time. Twenty-four hours after, at our third visit, we
were all disposed to wait no longer, l3ut to relieve the strangulation immedi-
ately; and when I least expected it, this hernia disappeared under my fingers,
and two days afterwards the patient was in good health. Although these cases
tend to prove that in general we must not take too literally the advice of Pott,
or Richter, and set aside the taxis from the first, yet I do not mean that they
should give too much boldness to the young practitioner. It is but too com-
mon to see in our days what Petit might exclaim against, as in his own time.
** How often is it seen that patients die the same day the reduction has been
made. In some the gut is found gangrenous ; in others it is burst, and fecal
matter poured into the abdomen." If we are to believe a medical journal,
this accident happened in the month of x\pril last in one of our great hospitals,
the very day on which the surgeon had dilated upon the dangers of forcible
taxis. I know besides that this misfortune happened a short time after-
wards in the same establishment. In both cases the intestine was. torn, and
The Lancet relates similar accidents occurring in the London hospitals, one in
particular under the care of Mr. Calloway. The case mentioned by Lassus
is not at all surprising, since the young man had conceived the singular idea
of using a stick by applying one end on the tumor and the other against a
wall. Therefore the point is not to reduce it at any risk, but only to know
how to make use of the taxis properly. Small, recent, and painful hernias
bear it ill ; because the opening which gave them passage is narrow, and very
tight ; because, moreover, the intestine thus bridled, inflames, becomes altered,
and often gangrenes 'with the greatest rapidity. The same may be said of
hernias which reappear suddenly, and become strangulated after having been
long retained by a truss. It is so much the more dangerous as the subject is
younger, more robust, and more irritable. In chronic strangulation it would
be imprudent to operate before recurring to it several times, and that even
with considerable force. The most of old hernias are of this class. The
presence of the epiploon, of a layer of fat, or of a portion of the large intes-
tine in the sac, diminish its dangers, because these several objects resist pres-
sure better than the small intestine. For the rest it is not the time elapsed
since the appearance of the first symptoms, but rather the state of the parts
which should regulate its application. In some subjects, gangrene or ulcera-
70
554 NEW ELEMENTS OF
tion supervenes almost immediately upon strangulation. M. Larrey found it
to occur in two hours, Richter after the lapse of eight, and Mr. Lawrence at
the end of twelve; while in other cases apparently similar, it had not been
manifested on the fifth or sixth day. In 1824, at the hospital of Improve-
ment, I operated upon Moliere, who had been four days affected with
strangulated hernia. The intestine, although livid, was not mortified, and the
cure readily took place. Some months afterwards another patient was car-
ried to the same establishment, to be there operated upon for a similar accident.
The symptoms which had existed but twenty -two hours, were exhibited with
less intensity than in the first. The hernia as in that case was crural. How-
ever, the intestine was perforated, and notwithstanding its liberation the
patient died during the night. On inspection of the body, alimentary sub-
stances were found efiused in the abdomen, and gangrene had invaded a great
part of the digestive tube.
As long as the skin is neither red nor very sensible, nor positively inflamed,
while direct pressure upon the tumor does not too much increase the suffering,
and while there is no very evident sign of a true inflammation of the abdomi-
nal peritoneum, nothing obliges us to abstain from it unless it has already
been tried by experienced persons. In the contrary case it would be best to
renounce it, unless no attempt whatever has been previously made. Every
thing is then to be apprehended, supposing even that we succeed, in returning
into the abdomen a half mortified intestine, if not a perforated one, and the
dark putrid matters, more or less acrid, which usually surround the sac.
When it is much inflamed, the operation is cseteris paribus the most certain
means to propose to the patient. It is scarcely more dangerous at this mo-
ment than the taxis, and has the advantage over it of removing immediately
every obstacle, and of not aggravating the condition of the viscera contained
in the tumor. If deferred, it will not be the same. The organs, contused,
lacerated, or gangrenous, do not offer the same hopes of success, and the ope-
ration perhaps may only hasten the transmission of the disease to the interior,
and consequently its fatal termination.
Instead of placing the patient as described above, some surgeons, Winslow
among others, were in the habit, in the last century, of putting them on their
knees, the head low and resting on the elbows, while the taxis was performed,
some credulous or bigoted souls took occasion from this to induce the indivi-
duals thus prostrate to make fervent prayers, pretending that if in this posture
their hernia was reduced, that it was to the divine interposition they should
ascribe it. A practice much more ancient, used also by Louis, Hey,
M. Ribes, &c., and which M. Jobert says was successfully followed by
M. Girauld, consisted in seizing the legs of the patient and hanging him up by
the hams upon the shoulders of an assistant who gently jarred him, while his
head and back rested upon the bed, or while another person performed the
taxis. It is possible that this resource may not be of much value, but it does
not seem to me to deserve the neglect into which it is fallen, nor the ridicule
which has been cast upon it at the present day. Mr. Lawrence is evidently
mistaken, when he says that the abdominal viscera are too exactly supported
throughout for the simple position of the patient to carry them more in one
direction than another. We may every moment have proof of the contrary
by observing on ourselves that the intestines float always to the most depend-
OPERATIVE SURGERY. 555
ing point of the abdomen ; in the vertical position towards the hypogastrium,
and towards one or the other side when we lie on the right or left. I conceive
then that by holding the patients by the hams there is some chance of the dis-
placed organs leaving the hernia to be carried towards the diaphragm, which
in this case becomes the inferior wall of the abdomen. There would be dan-
ger in doing so, for the same reason, if tlie intestine or peritoneum be already
inflamed or if from any other motive whatever, we have to dread all kind of
dragging on the part of the abdomen or the hernia. For the purpose of me-
thodising and generalising this succussion, Linacier of Chinon invented in
1819 a kind of pivot bed or tumbril covered with cushions, upon which he
fixed the patient so as to shake him more or less briskly by alternately letting
fall and raising the head of this apparatus. However ingenious it may seem,
this bed was not adopted and should not have been so. In the first place it is
not to be found every where, and is not indispensable, and then the patients
are stretched upon it at full length, while by suspending them by the hams
they may be kept flexed, and greatly bent upon their anterior plane. If suc-
■cussion is to be tried, this last mode of operating ought to be preferred as the
most simple, least dangerous, and quite as efficacious as any conceivable ma-
chine. I need not here remark that the taxis ought to be renewed with all
possible care, while the assistant or assistants keep the patient suspended ; that,
as in the case of the young man mentioned in the Lancet, it would be well
also to draw the abdominal wall upon the side opposite the hernia, and that the
concussions upon the pelvis are not indispensable.
2. Baths, — If the hernia is obstinate, the taxis should not be employed alone.
The bath is an accessory which is then scarcely ever to be neglected. It
calms or diminishes the pain, the spasm, the rigidity of the tissues, the tenes-
mus, and inflammation itself if exisiing. It is used of the temperature of 28°
or 30° Reaumeur (100° Fahrenheit) or a little lower. The patient remains in
it from one to two hours. Desatilt directs a cloth suspended at its four corners
so as to make a kind of bed of the body of the bathing tub, where the patient
may lie moderately flexed and be subjected to further attempts at reduction.
Some practitioners repe9<: it once and even several times during the day, that
is, when the tumor is Piore urgent or the operation not decided on. However
if more powerful means have been employed it would be useless to have recourse
to it, and lose precious time in inefi'ective efforts. Although the warm bath is
proper in almost every species of strangulation, it is in acute, inflammatory,
intestinal strangulation, in young and robusts subjects, that it ought particu-
larly to be ased. As it has not, like the taxis, the disadvantage in case of
failure of increasing the danger ; as, if the operation may have become indis-
pensable, it can only be favorable to success, there is no reason to neglect its
use except in cases which will not allow us to temporize.
3. Bloodletting, — The unanimity of surgeons in regard to the utility of warm
batliing in cases of herniary strangulation is not so complete upon that of blood-
ietting. Although extremely extolled by Dionis, by almost all the academy
of surgery, by Pott more than any one else, and recommended by the most
distinguished authors of our day, it has been as it were proscribed by Wilmer,
Alanson, and Sir Astley Cooper. Dr. Hey also acknowledged that it is most
frequently useless, and that it was necessary to restrain its use. The surgeon
of Coventry condemns it as enfeebling the patient without favoring th€ reduc-
556 ' NEW ELEMENTS OF
tion in the least. It has, says he, influence neither upon the aponeurotic
opening, nor on the strangulated viscera; it can no more enlarge the one than
diminish the size of the others ; in fine, it remains to be proved whether blood-
letting has ever removed a well attested strangulation. To these objections,
the principal fault of which is their being too absolute, we have first to oppose
the experience of every age, which has often demonstrated that a hernia
resisting the taxis until then, has been very easily reduced after copious bleed-
ing. By producing a general shock, this means is calculated to facilitate the
return of the displaced organs, to diminish the resistance of the muscles, the
engorgement of the tissues, local congestion, by consequence the volume of the
strangulated parts, and thereby all inflammatory fluxion. Carried to syncope,
bloodletting puts in motion the peristaltic action of the intestines, so that after,
they return completely of themselves under its influence. Thus it will be
well when we wish to attain this end, to open the vein largely and keep the
patient erect during the bloodletting. To understand the importance of
bloodletting it is necessary to specify the cases that require it. Obstruction,
epiplocele, and every species ojp strangulation in the aged would be rather ag-
gravated than diminished by it. Delicate subjects and old hernias do not
bear it without inconvenience unless it is formally indicated by well marked
inflammatory symptoms. On the contrary, in young and robust persons ^vvith
recent, acute, intestinal strangulation, it is of incontestible utility, and should
rarely be neglected were it but to extinguish or lessen the phlegmasiac move-
ment tending to invade the abdomen. It would be improper however in any
case to fix upon it, like Pott, an exaggerated value. It v/ould not be very ra-
tional to depend on its efiicacy after repeating it two or three times, even in
patients in whom it is best indicated. It is an accessory means, which like
the bath will rarely of itself suffice, and in truth only deserves so much con-
fidence, because it serves at the same fniie as a precaution against future
accidents
4. Purgatives, — In the last century, Legrane., a surgeon of Aries, proposed
the use of Epsom salts as a kind of panacea in sti;»ngulated hernia. Accord-
ing to him this medicine incites and titillates t\ie htestine, and frequently
causes it to re-enter the abdomen and discharge tK<^ niatters which may have
accumulated therein. Most violent purgatives, emetics m nauseating doses,
ipecacuhanha for example, have been also recommended. Richter and He-
berden, who have employed them, profess to have obtainexl real advantages
from this exhibition. In France they have never enjoyed mu^h. reputation,
and the medical ideas attempted to be spread for the last twenty years, have
not been of a kind to bring them into favor among us. Although their irritating
action is infinitely less dangerous than some have imagined, yet in my opinion
it would be hazardous to trust to them in acute or inflammatory strangulation.
I would employ them freely, on the contrary, when there is only epiplocele,
or fatty hernia, and the course of. substances is not mechanically interrupted
in the digestive tube ; and even in entcrocele w^hich is only strangulated from
obstruction and does not threaten inflammation. As they solicit the secretion or
exhalation of a great quantity of fluid and a vernacular motion more evident
in the superior portion of the canal, as they may produce the re-establishment
of the stools or the softening of the obstructing substances, it is easily con-
ceived how they may have had success, and still preserve partisans, as M.
OPEUATIVE SURGERY. 557
Gaussail gives proof quite recently in the weekly journals. But it is a species
of remedy too difficult to manage, too treacherous, and too rarely useful for me
to venture formally to recommend it. The following however is a case which
I cannot pass by in silence. A woman thirty -two yfears old was in the
fourth day of a strangulated hernia. Every thing had been tried, baths, bleed-
ing, taxis, and clysters of all sorts. The belly was tympanitic and painful.
The vomitings, constipation, pulse, and countenance left no doubt as to the
dangers under which this woman must sink if the operation was not performed
without delay. The patient positively refused to submit to it. Having
nothing further to hope I gave her every thing she desired. At her earnest en-
treaty some milk and a purgative were administered to her. During the
day she took two ounces of castor oil. The symptoms continued until 5 o'clock
p. M. but shortly afterwards were calmed, and at my visit the next morning,
the students who had watched her and myself could not have been more as-
tonished at finding her out of all danger. Her recovery was complete.
5. Opiates. — Antispasmodics, opium, and other substances capable of modify-
ing the general economy, whether singly, or combined with purgatives as
Richter, Heberden, &c. were in the habit of employing them, scarcely deserve
to be called to the notice of the reader. The sole advantage they can promise
is to calm for a time, to palliate the colics, nausea, distress, in fine some of the
symptoms produced by the strangulation ; but to terminate the strangulation
itself is not in their nature. I do not see why belladonna which was for a long
time extolled, and given in a large dose as directed by M. Chevallier, can be
of more avail than opium. The oil of turpentine, given by Drs. Sewall and
Mc Williams in the quantity of two ounces at a time, so that the patient swal-
lowed eight ounces in twenty-four hours, will probably never be tried in
France, and therefore deserves merely a passing mention, notwithstanding the
success attributed to it in America.
6. Enemata. — At the same time that one or all of the preceding means are
employed, it is customary to solicit the large intestine. The principal inten-
tion being to provoke the passage of matter situated below the strangulation,
or at most to produce an anti-peristaltic motion in the whole of the digestive
tube, some persons use simple, laxative, or common purgative injections.
Riviere thought that by injecting air into the anus by a bellows the displaced
organs might be returned into the abdomen. MM. Hufeland and Van Loth,
pretend to have cured several patients by injecting hyosciamus or belladonna
into the passage, as is also recommended by M. Pauquy in his thesis. But in
this view tobacco is the substance most employed. It is given in smoke by
means of an apparatus that every one can invent and construct; or, which is
at once more convenient and certain, in infusion \\\e, same as any other clyster.
In this last case a dram of tobacco to a pint of water is the proper dose, winch
it might be dangerous to exceed. Sir A. Cooper has seen it cause a kind of
poisoning, which actually occurred in another case in which two drams were
used ; and the same accident has happened since in the ward of M. Marjolin.
Without believing with Heister, that it is an infallible remedy, or with Pott,
that nothing further is to be hoped for after using it in vain ; without giving it
the same confidence as Hey, Lawrence, Rose, and the greater part of English
surgeons, it cannot be denied that the tobacco clyster has more than once,
removed the strangulation and rendered the operation unnecessary.
558 NEW ELEMENTS OF
For myself I have seen but one case, but it was a remarkable one; every
thing was ready for the operation, yet before it took place M. Richerand had
occasion to send for something out of the hospital. During this time a tobacco
injection was administered, and when about to expose the hernia we all saw
to our great surprise that it had been reduced. The symptoms ceased at the
same time, and the young man left the next day to resume his ordinary occu-
pation. It is true I have seen it employed again in the same hospital, and I
have used it since in twenty-five cases at least without any benefit. The
oppressio viriunif the deep colics, the cold sweats, the tendency to convul-
sions which it usually produces, are evidences of the energy of its action. As
it determines at the same time violent vermicular contractions in the whole
length of the intestinal tube, nothing is easier than to understand the effects
attributed to it in strangulated hernias. For the same reasons that render it
powerful and of incontestible utility, tobacco may be sometimes dangerous.
When the constriction is very decided, the hernia recent, purely intestinal,
and complicated with inflammation, and the strangulation acute, prudence
opposes its employment. On the contrary, it is very proper in every kind of
obstruction, and strangulation of the large intestine and of the epiploon;
whenever in fine the inflammatory symptoms are but little developed, and
there is no reason to fear the effect of tractions upon the displaced organs.
After trying it in the dose of a dram, under these circumstances, we may
and ought, if it produce nothing manifest, repeat ijt pnce or oftener, and throw
up two drams at least provided no narcotism nor other general accidents are
to be apprehended.
7. Topical ^ipplications. — Leeches. Cataplasms which have been advised
and used by a number of practitioners, can be of no real use except in very
few cases. If the tumor is neither hot, nor tense, nor painful, nor really in-
flamed, their usefulness is more than doubtful unless they act from their
weight ; and if the contrary condition exist, we cannot wait long enough for
their emollient properties to produce any effect. For the rest, as they do not
interfere with the use of the bath, bleeding, and tobacco clysters, I see but
little inconvenience in covering the hernia with them in acute strangulation
as long as the operation is not urgently demanded. It is otherwise with
respect to leeches, which many apply upon or about the tumor. Experience
says nothing in their favor, and reasoning proves that they may be injurious
in every hernia without inflammation, and in inflammatory strangulation itself;
for there they can at best but act against an effect, while it is the cause that
should be removed. The ecchymoses which result from them have besides
the disadvantage of increasing the thickness of the herniary envelopes, of
deforming and deranging them, and thus rendering the operation more diffi-
cult. If they are ever useful, it is at most in strangulation of an inflamed
epiplocele of some adipose tumor or other independent of the intestine. Re-
frigerants perhaps deserve a little more attention. Compresses wet with cold
water, ice water, chloruretted solution, vinegar and water, frictions with acetic
ether, all the means in fine which when applied upon the tumor remove a
large proportion of caloric, may favor the reduction in three ways; 1st, as
discutients by diminishing the afflux of the fluids; 2d, by condensing the
gaseous fluids in the strangulated loop of intestine ; 3d, by soliciting the
peristaltic action of the. digestive tube. It is seen from this simple enumerar
OPERATIVE SURGERY. 559
tion in what cases they would be proper, and what it is reasonable to expect
from them. A much more powerful mode of employing them is one followed
by some old women in the country, and described by J. L. Petit. Being
called to a young man to operate, this author, accompanied by some of his
professional brethren, was ready to commence, when the grandmother of the
patient entering the chamber attempted to drive them all out, and said she
was going to cure her child off hand. After extending him naked upon
the floor, she ran to the well and drew a bucket of water, which she threw
suddenly upon the hernia. The fact is, says J. L. Petit, who requested pei-
mission to be a witness of the experiment, that the intestines returned almost
immediately, and the young man was cured without an operation. Every one
understands the action of these means, and that they miglit be employed with
some confidence, if when unsuccessful they were not of a nature to favor the
development of the numerous phlegmasiae which sometimes follow hernio-
tomy. In order that gangrene from congelations, noticed by Sir A. Cooper,
be feared, ice, snow, and every other, even the most powerful refrigerant,
must be used with very little precaution, and I doubt if such an accident is
really to be apprehended. Much has been said of the belladonna of late in
the reduction of hernias. M. Speziani made a pomatum of it with which he
smeared the tumor; MM. Meale, Pages, Faye, and Magliari, did the same
with success; M. Saint- Amand was not less fortunate, using it in cataplasms ;
M. Riberi covered a bougie with it, which he introduced into the urethra, and
declares that he has in this way been successful. M. Guerin of Bordeaux,
long since used opiated bougies, daily introduced into the canal of the urethra
as a remedy for herniary strangulation. To say that great confidence may be
reposed in such means I cannot ; but as they are of easy application as well
as void of danger, I see no reason why they may not be used when there is
no need of an immediate operation. I have employed them six times. The
tumor, greased morning and evening with the ointment of belladonna, was
covered with simple cataplasms. Twice I introduced the same substance
into the anus on a strong bougie, and I must confess that several of the pa-
tients seemed to be relieved. As for explaining their mode of action, we
must wait I think until a greater number of facts are given in their favor.
8. Acupuncture. — Galvanism. I do not speak here of astringent cata-
plasms, as the promegranate and decoction of walnut leaves which Belloste so
much recommends, supposing them to have been long since generally aban-
doned ; but I cannot dispense with saying something on acupuncture and
electro-puncture. Since the time of Pare, surgeons have sometimes ventured
to pass a long needle or small trocar once or oftener through the hernia, for
the purpose of giving vent to the gas contained in the strangulated intestine.
Pott says such a practice is absurd, and does not require refutation. Most
of the moderns are of the same opinion. It has nevertheless been employed
in my presence on a patient upon whom I operated immediately afterwards ;
and I am assured by a young candidate in medicine, that his father has often
tried it with success. I think it ought to be rejected ; first, because it cannot
rationally be applied but to enterocele distended with aeriform fluids, and
secondly, because one of these two things occurs ; either the small wound
closes when the needle is withdrawn, and it is as if nothing had been done,
or it remains open, and in this case it is to be feared that the intestine when
560 NEW ELEMENTS OF
returned into the abdomen may allow the escape of some particles of the
fluid usually contained in it. This last accident however cannot easily take
place, for every traumatic perforation of the digestive tube, which is not more
than a line or two in breadth, seldom fails of being Immediately obliterated,
either by the approximation of its edges, or by a swelling of its mucous mem-
brane. For the rest acupuncture is a bad means, and if it is to be tried at all
a very fine canula should at least be used, which may give passage to the gas
after being introduced into the tumor by the needle. Electro-puncture with
which M. Leroy (of Etiolles) has made experiments upon dogs, has not to
my knowledge been yet applied to man. It consists in placing by means of
a steel point, one extremity of an electric or galvanic circle in the tumor,
while the other extremity of the same circle is placed upon the tongue or
anus, according as the hernia is formed of the small or large intestine. The-
ory teaches that the currents or discharge from a pretty strong pile or trough
thus directed, are calculated to create in the displaced viscera sufficient move-
ments to sometimes determine their return intp the abdomen. It is for expe-
rience to confirm these conjectures. After all the resource is easLily tried in a
better way than by electro-puncture, as it may be applied by means of simple
electric circle without needles.
Recapitulation. — Let us imagine the practitioner supplied with these various
means, actually in presence of an individual affected with strangulated hernia.
Suppose it an old enterocele become all at once irreducible. If attempts
have already been made, before renewing them he will have the patient placed
in a bath, and commence by a copious bleeding from the arm if he is robust
and threatened with inflammation. If the taxis does not then succeed, the
large intestine is to be emptied by means of laxative enemata. Tobacco
infusion will have its turn two or three hours after. If the state of the forces
permit, the bleeding is to be repeated together M'ith the bath and the taxis ;
then come the frictions with belladonna, and the bougies, according to the
method of M. Riberi, or M. Guerin. If all is insufficient, and there is no
urgency, embrocations, cold applications, compression, and lastly, electricity,
may be tried. In cases of acute strangulation,' of recent hernia, the taxis,
bleeding, baths, clysters, cold or narcotic applications should rapidly succeed
one another. If there is already inflammation in the tumor, the tobacco in-
jections, electricity and compression are no longer applicable. The taxis
also should be performed with the greatest precaution. If the pain and other
inflammatory symptoms leave no doubt as to the state of the parts, blood-
letting and bathing can only be considered as preparatives; all topical appli-
cations should be neglected, and the operation performed as soon as possible.
Leeches in great number, and emollient cataplasms will only be proper when
the symptoms seem to depend on an epiplocele or tumor foreign to the intes-
tine. When the hernia is formed by the large intestine, or the progress of the
symptoms is tardy, we commence with the taxis or the bath, then have recourse
to tobacco clysters, opiates or belladonna, refrigerants, and electricity itself;
but venesection should or may be most frequently omitted. The same course
is followed when there is only obstruction ; and in this case, in the intervals
between the use of the taxis, compression by means of a proper bandage may
be of service, as in case of epiplocele, freed from adhesions and inflammation.
In fine, having tried every thing, and modified our attempts according to the
OPERATIVE SURGERY. ♦ 561
nature of the symptoms, if the hernia be retained by adhesions, or if the ring
oppose an invincible resistance, we must not think of reducing it. If there
be yet time, celotomy, in which the chance of success is the greater and the
danger the less the earlier it is eraployed, should no longer be deferred. As
the treatment required by the patient is the same after reduction, as after the
operation we will not refer to it at present.
§ 4. Herniotomy or Celotomy.
A. Enterocele. — The operation for strangulated hernia was not posiiively
known before Rousset. Maupasius seems to have been the first to point out
its advantages. Until then celotomy was performed only for the purpose of
protlucing a radical cure of ruptures. It consists of several stages : incision
of the integuments, division of the tissues situated between the cutaneous en-
velope and the peritoneum, opening of the sac, examination and appreciation
of the strangulated parts, destruction of the strangulation, and reduction of the
displaced viscera ; such are the phases through which the surgeon proposes to
run, after arranging his apparatus, the patient, and the assistants.
Jlpparatus. — A fold of lint spread with cerate and sufficiently large, rolls
and dossils of charpie, adhesive strips, obiong or square compresses, a long
roller or rather a special bandage, a straight bistoury, a convex bistoury.
Pott's concave bistoury, a straight probe-pointed bistoury, good dissecting
forceps, straight scissors, a director without cul-de-sac, several ligatures and
needles, in addition to the accessories of every great operation, are the various
objects necessary, which are to be placed in order on a large dish, or on a shelf.
Position of the Patients and Assistants. — The table covered with a mat-
tress, or the bed. on which the patient is laid, requires nothing particular
except to be properly protected by cloths, and of a convenient height and
width. No one at present imitates Louis in sitting on- a stool between the
legs of the patient held on the edge of his bed. They stand, kneel, or sit on
the right. The patient, in a horizontal position, and nearer the right side than
the left, is in a state of complete relaxation. An assistant watches the mo-
tion of his head and arms, anotlier attends to his inferior extremities ; a third
stands opposite to the operator to stretch the skin, sponge the wound, &c.;
the fourth is free, and is charged with handing the instruments.
First Stage. — The parts should be previously shaved, washed, and dried.
If the skin be too tense, too thick, or too adherent, the surgeon with a convex
bistoury divides it as in simple incision from without inwards, taking care not
to go too deeply at first. In the opposite case he takes up as large a fold a^
possible, one extremity of which he gives to an assistant, and immediately
divides it either by puncture from within outwards,, or which is better, from
its edge towards its base. This fold has the advantage of less exposing the
viscera to be cut, but the incision is less regular, and can never be prolonged
sufficiently at a single stroke, if the hernia is voluminous ; so that aeteris
paribus simple incision is preferable when we are sure of one hand. The
wound should be in the direction of the greatest diameter, and of an extent
proportioned to the volume of the tumor. We do not give it the T or crucial
form except in particular cases. When it is not long .enough at first, instead
of passing a director successively under each of its angles, to enlarge the
71
i
562 * NEW ELEMENTS OF
wound with scissors or the straight bistoury, the operator takes up one of the
]ips and directs the assistant to take the other, so that the index finger rests
in tlie wound and the thumb on the skin at the inferior end ; the thumb in the
wound and the finger on the integuments at the superior end ; he separates
them a little, reflecting them outwards, and then with the convex bistoury-
enlarges the wound as much as he thinks necessary. By the other method
much more pain is produced, the skin slips over the director, puckers, and is
incised with difficulty. The vessels opened during this first incision are
rai'ely large enough to require the ligature. It is usually sufficient to rub
them a little, or to have the assistant's finger applied over their orifice for a time
to stop their bleeding ; otherwise twisting them is a very simple thing.
Second Stage. — The division of the laminae which come after the skin
requires the greatest attention, and should be m.ade very slowly. In fact,
they are not sufficiently distinct from each other, nor sufficiently uniform in
respect to thickness to insure us against wounding parts which it is important to
save, or to permit us to proceed with extreme reserve, feeling our way carefully
until we arrive at the sac. The most certain way is to take them up with the
forceps as they present on a projecting point of the tumor by small portions
at a time; to cut them off" successively with the knife, and renew this ma-
noeuvre as long as the sac continues concealed. The director carried upwards
and downwards through this species of aperture as far as the extremities of tlie
wound, allows us to incise them with safety with the straight bistoury or scissors.
No one will now pretend to tear them with the sharp pointed probe of Le Dran,
or the gum lancet which was used even in the last century. It is on approach-
ing the sac that the difficulties begin. In some subjects, or in certain hernias
it is separated from the skin only by a very thin layer, in others it is found at
several lines and even several inches in depth. To arrive at it, we are some-
times obliged to pass through several lardaceous layers, imposthumated lym-
phatic ganglions, and circumscribed or diffused purulent collections; in fine, it
may be immediately surrounded with some considerable quantity of bhickish
serosity (of which Mr. Travers and M. Richerand each give an example),
very apt to make us think that we have penetrated its interior, or with
diff*erent kinds of adipose expansions, which may be easily mistaken for the
epiploon.
Interposed adipose layers. — It seems that this last anomaly is by no means
infrequent. Saviard reports a case of it. It was also met with in a patient
operated upon by M. Lisfranc. I have had myself four cases. If it be true that
the error may often be easily avoided, it cannot be denied tliat it is sometimes
necessary to use the greatest caution not to commit it. When the fatty layer
covers the whole of the external face of the sac In the manner of a cloth, or
when it is even surrounded by a humid, fine, and polished membrane without
adhesions, such an arrangement may embarrass even the most skillful. M.
Roux himself barely avoided the mistake in 1825, at the hospital of Improve-
ment. After dividing the integuments and several cellulo-adipose lavers, he
came to a brownish membrane, very distinct from the others, opened it with
precaution, and finding it smooth and covered with an unctuous serosity on its
interior he thought he had opened the sac. Beneath was seen a yellowish mass,
porous, and very flexible, but not an intestine. Fearing that this mass might
be the intestine covered with the epiploon, M. Roux took the nrecaution of
OPERATIVE SURGERY. 563
dividing it layer by layer has he had done with the rest. Instead of the
intestine, the true sac shortly presented itself, after which there was nothing
remarkable in the hernia. The abnormal production does not always sur-
round the whole of the sac. In 1829, a patient, inadvertently placed in the
medical wards of the hospital St. Antoine, was sent the next day to my care.
Strangulation was then of several days' standing. The membrane which I took
for the sac being opened, there appeared a mass composed of two parts, the one
globular, dark, and smooth, of about the size of a small egg, situated pos-
teriorly and inwards ; the other larger, less dark, knotty, and placed against
the anterior and external half of the first. The idea of an entero-epiplocele
immediately struck me. But in attempting to insulate the fatty portion in
order to proceed to the reduction, I perceived that the intestine was not laid
bare and that a semi-transparent lamina still separated it from the other tissues ;
this was the real sac, the neck of which gave attachment by its external face
to a true fatty hernia which I excised. A laundress, to wliom M. Forget
called me, presented an arrangement not less singular. I had also opened a
membrane which might be mistaken for the sac. The tumor it contained was
trilobed, and its three lobes were of unequal size and a very deep brown
color. We readily discovered that the viscera had still another covering to
be divided. The internal bossehire alone belonged to the intestine, it had a
particular sac ; the two others had also a distinct covering, were pedunculous,
of an adipose nature, and fixed to the external face of the herniary peritoneum.
I excised them after reducing the intestine, and the patient got well. I
operated at La Pitie in October 1831, on an old woman who presented an
arrangement exactly similar to that in the first case. These fatty vegetations
may assume a thousand other forms. Thus M. Tartrie met with a hard
oblong tumor, which he could not reduce, and which he took for degenerated
intestine, and cut off for the purpose of establishing an artificial anus. The
patient died, and lo ! the intestine had not been touched. There was not even
enterocele ; it was an adipose hernia which had been removed.
A cysty resulting from an old herniary sac, or of any other nature, empty,
like the one in the patient operated upon at La Pitie by the method of M.
Belmas, or filled v;ith fluid, as many authors have observed, may occasion
mistakes of another description which every one can conceive ; mistakes so
much the more easily occurring as the sac Itself after being inflamed and
transformed into an abscess, may give rise to most of the symptoms of stran-
gulation, as has been said above.
Third stage. — But being once aware of the possibility of so many mistakes,
the experienced surgeon will almost always succeed in avoiding them. The
sac is unopened as long as there is seen a surface rugose, tomentose, uneven,
a mixture of layers or lumps, adipose, vascular, cellular, or lamellated; as
long as the neck of the tumor is not free and does not allow us to feel around
its circumference within the ring with the nail or the end of a probe. Cysts,
abscesses, &:c. are distinguished by their want of communication with the ab-
domen. It is the same with all morbid productions situated without the
peritoneum. Supposing, besides, that an adipose layer may be mistaken for
the epiploon, what danger would there be in tearing it prudently in order to
see what is beneath ? Unless there are peculiar difficulties, we ought only to
lay bare the sac in the direction of the wound of the integuments. By trying
564 NEW ELEMENTS OF
to dissect it, and separate it carefully from the surfoiindlng tissues, the
surgeon prolongs the operation, increases the amount of pain, and renders
mortification of the process of the peritoneum almost inevitable, if its excision
is not immediately performed. In the more simple hernias, the opening of
the sac is easy and without danger to the man possessed of exact anatomical
knowledge and a little skill. The intestine constantly presents some inequa-
lity and is not so exactly globular as its peritoneal covering, which besides is
usually separated from it by a layer of serosity or lic[uid matter of more or less
thickness. In this case we may in some measure, as Louis did not hesitate
to affirm, cut at a single stroke the skin and the principal layers which sepa-
rate it from the sac, and then with a second stroke without hesitation pene-
trate this last envelope. In other and rather complicated cases, this proceeding-
would amount to rashness, and would truly deserve the blame which has
been cast upon it. When there is in the sac but a small quantity of fluid,
it does not prevent us recognizing the presence of the intestine within. What
may lead to error is the entire absence or the excess of fluid in this pouch.
It is readily perceived how easy it would be on the first hypothesis to cut as
^eep as the viscera, and divide them without perceiving that we had passed
the sac. The difficulty would be in every respect much greater if the various
parts were united by adhesions. In the second case the danger only lies in
the possibility of confounding it with a large portion of intestine distended
with gas or any liquid substance, supposing here that the sac could not yet
be distinguished.
Dropsy of the Sac. — The presence of a large quantity of fluid in the sac is
too frequently met with not to require notice in this phace. An observation
of Saviard mentions it. Merry found more than a pint in the case of a woman.
M, Liegard of Caen, and M. Roux, have each met with a case. Schmucker
and Siebold arc said to have been on the point of being deceived, and of sup-
posing that they met with a hydrocele. Monro asserts that he found more
than six pounds, and Scarpa more than three in a single sac. Pott several
times tapped for this complication, which Mr. Lawrence appears also to have
met with. In fine, in a thesis which he lias just defended. M. A. E. Mare-
chal has assembled several cases, picTied up by him at La Charite. In order
that it should occur, too conditions are necessary; the neck of the sac must
be first closed by stricture or in some other manner, and then the peritoneal
process must become the seat of an unnatural exhalation. The other affections
which may to a certain degree simulate it, are vesical hernia, an hydrocele
which shall have an old closed hernia sac foi its seat as witnessed by Butrandi
and Pelletan, or large hydatic cysts developed on the strangulated epiploon,
like the one nientioned by Lamorier. I have myself observed a case perhaps
more extraordinary still than any of those as yet related ; an old man quite
robust was brought into my ward at St. Antoine in October 1828, to be treated
for an enormous hernia, attended for five days with constipation, vomiting,
and ether symptoms of strangulation. This hernia which occupied the scrotum
had double the size of the head of an adult, was heavy, tense, brownish,
slightly painful, covered with veins gorged with blood, and had no crimpling
on its surface. Fluctuation in it was obscure, so thick wore its parietes, and
the light of a taper gave but very vague indication of its nature. The patient
told us he had carried it for fifteen years without its being larger than his fist.
OPERATIVE SURGERY. 565
and that several times he had succeeded in reducing it. I did hot hesitate to
open it, proceeding with the same cautions as for ordinary hernia, that is,
dividing its coverings layer by layer", and on one point only. As soon as it
was pierced there escaped with a forcible jet a liquid as clear as wine. I
immediately enlarged the opening and drew off more than three litres of a
slightly turbid serosity. Its superior part contained besides an entero-epiplo-
cele about as large as the fist, which was powerfully strangulated, and had
several gangrenous spots. By calling to mind the natural signs of simple
hydrocele and cystocele, there will be but few difficulties on this head. The
mistake, besides, would not be very serious. It is only necessary to know
that such a complication would render the efforts of tlie taxis nearly useless,
since the fluid absorbs them before they reach the intestine ; and on the otiier
hand this fluid must favor the strangulation by its reaction upon the viscera. '
It is then as in every other case, the intestine with which we should be careful
not to confound the sac thus filled with fluid. In order that it shall be impos-
sible, we must suppose an intimate adhesion between these two parts, a kind
of confusion of the visceral peritoneum with the parietal peritoneum of the
tumor, which except in very old or coecal hernias is quite rare.
Provided there is no sac, even when adhesions may exist, it does not appear
how it can be absolutely impossible to recognise the intestine if proper care
be used. The sac in its natural state is but a simple lamella and can only be
surrounded by lamellse. Whatever thickness it possess, whether depending
on the cellular tissue which covers its surface, or on accidental layers deposited
on its internal face, it will always be presented under the form of con-
centric layers unequally superimposed ; while the meeting with a fleshy
covering wdth a double plane of fibres beneath a completely adherent serous
expansion will not permit us to mistake the intestine, nor to penetrate the
interior of this organ if we wish to avoid it. A note by the translator of
Scarpa, in whidi it is said that a provincial surgeon divided the intestine,
because the adhesions which united it with the sac did not permit him to dis-
tinguish these two parts, the accident which happened the last year in one
of the great hospitals of the capital to the superintending surgeon, who also
penetrated the intestinal canal in operating for a hernia, as well as many
other mistakes of the same description, seem, it is true, to ri§e up against the
opinion I have just advanced; but viewing it more closely, setting aside the
authority of names, and with the desire of coming exactly at the truth, we
shall not be long in perceiving that the error in these different cases was not
inevitable, and that the blame should be attached rather to the inattention of
the operators than to the nature of the case. The practitioner mentioned by
M. Olivier, for instance, says that before arriving at the sac, he had to pass
through a cyst filled with brownish serosity. But it seems evident to me that
this pretended cyst was the sac itself which he did not recognise. Hence it is
that he opened the intestine thinking it only the herniary covering. However
this may be, we may proceed in two ways to the opening of the sac. The
first, and that which is generally followed, consists in seizing it with the
forceps at the point wliich seems most free, so as to raise a small flap, which
is excised by carrying the bistoury horizontally beneath the beak of the in-
strument. The fluid, if it contain any, immediately issues through this open-
ing, unless the intestine is immediately engaged in it, which is distinguished
566 NEW ELEMENTS OF
by its greater pliability, by its more mellow appearance, and its other natural
characters. A conductor, carried through this opening, is then used in enlarg-
ing it as much as is desired, and protects the viscera against the action of the
probe-pointed bistoury or blunt scissors which are then to be employed. The
other method is apparently more dangerous, and hence is generally condemned
by authors. But I have constantly found it more simple than the preceding,
and would therefore not hesitate to give it the preference if we could rely
sufficiently on the hand of every one who operates for strangulated hernia.
While the left hand stretches sufficiently the sac or tumor, the right, armed
with a straight bistoury held as a pen, draws gently and with small strokes
the point of the instrument over the prominent parts, divides them layer by
layer, and thus allows us to distinguish all the laminae which present, to stop
when we please, and to penetrate quite as safely as by the ordinary process.
In every case, the rule is to open the sac as far as the lower part of the
tumor, so that its inferior portion may not serve as a receptacle for pus or other
fluids that may accumulate in the bottom of the wound. Many surgeons
advise the same to be done at the superior part ; but others, of a different
opinion, direct the incision to extend only to within a certain distance of the
ring. They contend that by this they expose the patient less to peritonitis,
or the surgeon to go wrong in removing the stricture, provided that then it
becomes impossible to introduce the bistoury between the neck of the serous
tunic and the aponeurotic opening, as, it is said, has sometimes happened. If
names such as J. L. Petit and Astley Cooper were not their defenders these
operative minutiae would not deserve notice. Has the question been seriously
discussed whether it is proper or not to prolong a few lines more or less the
incision of the sac, in this or that direction r Those who have performed the
operation for strangulated hernia cannot be made to understand that the
removal of the stricture can be rendered either more or less easy, or perito-
nitis either more or less to be dreaded by one or the other of the modes of
proceeding. When the root of the parts to be reduced has been laid bare, the
object is accomplished. For the rest, it is of little consequence whether the
incision of the peritoneal process extend into the ring, or stops a few lines
short.
Fourth Stage. — Freed from "every obstacle to their expansion, as soon as the
sac is largely opened the viscera often suddenly acquire a much more con-
siderable volume than had at first been supposed; so as even to lead to the
belief that a new portion of them has just escaped through the herniary open-
ing. At length they are in view. Before going further, we must appreciate
their condition and ascertain the seat of stricture. When the hernia is not
very large, inflammation has often united its several folds together or to the
sac. Gentle traction or passing the fingers between the parts is always suffi-
cient to separate them in such cases. If old adhesions organised, filamentous,
in form of chords, or cellular prolongations, prevent their complete insulation,
a bistoury or scissors will soon despatch the business. General adhesions, so
intimate as not to permit us to perceive any line of demarcation between the
sac and the hernia, should alone be respected. In attempting to destroy them
it would be difficult not to make some slips in the direction of the intestine;
or if, to obviate this danger the instrument is carried more outwards, the
viscera remain loaded with too much foreign tissue, rendering their reduction
OPERATIVE SURGERY. 567
doubtful. If they are strangulated by a rent in the sac, or in the sac itself, by
a rupture or band of epiploon by an accidental cord, or in any other way, we
begin by setting them free in order to spread them out and see if they are not
the seat of a degeneration, whether ulcerous or gangrenous ; in a word, to see
whether or not they are in a perfectly sound state. Having thus spread out
and examined them, we should replace them in the abdomen if the stricture of
the ring offer no obstacle. In fact, this is possible in a certain number of cases.
In the first place, when the abdominal opening is not the seat of strangulation,
and when besides, the course of the matters has not been interrupted by a too
abrupt inflexion of the organs on the herniary orifice, moreover when the
substances accumulated in the intestinal loop, are of sufficient fluidity for a
methodical pressure to return them behind the ring. Nevertheless, before
attempting it, whatever be the state of the parts, all that portion should be
drawn out which is found in the aponeurotic passage. Without this precaution
we run the risk of returning into the abdomen a portion of intestine, con-
stricted, obliterated, ulcerated or more or less extensively altered, which
although seeming perfectly sound externally, may be absolutely incapable of
performing its functions. Besides, another advantage results, which is, that
the loop being longer, the matter it contains are spread over a greater surface,
distend it less, diminish the volume of each of its rings, and thus render its
reduction more easy. Its coarction in the ring is a known fact, admitted by
all authors, and which the observation of Ritch has placed beyond doubt. In
a patient operated on by this surgeon, the symptoms continued after the
reduction. Death was the consequence, and the opening of the body showed
the cause ; the portion of intestinal tube which had been strangulated, was
found so contracted as scarcely to allow a passage to a common quill. A
more frequent lesion, and one which in my opinion has not been sufficiently
noticed, is ulceration of the intestine on its external face. It presents
the appearance of a furrow, one to two lines broad, occupying sometimes
several points, sometimes even the whole extent of the intestinal circumference,
and corresponds to the fibrous circle which has caused the disorder. It
might be called a wound produced by a cord tied too tightly. As long as
the peritoneal tunic alone is deceased, as the muscular membrane is not
entirely cut through or the mucous membrane preserves its thickness, the
whole may be replaced in the abdomen without danger ; but then the greatest
care will be necessary, for these various tunics being at the same time more or
less softened, the least pulling may terminate in a rupture, as I witnessed in
the case of a female operated upon under the direction of M. Roux, and who
died the next day. Mr. Lawrence and M. Roux, who with more earnestness
than M. Boyer have called the attention of practitioners to it, might have
added that this traumatic fissure has more than once gone so far as to perforate
the intestinal tube and produce a fatal effusion, the origin of which was
improperly referred to gangrenous ulceration. A woman fifty-five years old,
was brought in ] 824 to the hospital of Improvement. I operated immediately
for a strangulated hernia of forty hours' duration. After removing the
stricture, I reduced the intestine with the exception of its most projecting part
which was gangrenous, the opening of which I retained in the ring. The
organic contour which liad supported the constriction, presented the above-
mentioned ulceration, and near its mesenteric border, there was a perforation
5G8 NEW ELEMENTS OF
through whicli the fluid matter poured into the peritoneum. The reduction
therefore should nev^r be accomplished in any case without previously
bringing the sac, for examination, that portion of the viscera which has
been originally contained in tlie fibrous circle of the abdominal wall. If it
resist, or any difficulty be experienced in returning it, we should without
hesitation enlarge the opening through which it has passed — we should finally
remove the strangulation.
Fifth Stage. — ^The seat of this strangulation, is not in every case the same.
In the circular openings it may be. produced by the neck of the sac, or by the
fibrous circle which embraces it. In a canal, it is found, as I have already
stated, sometimes at the external orifice, sometimes at the posterior orifice,
and at other times between the two. Strangulation by the neck of the sac
occurs only in old hernias, or in those which liave protruded and been reduced
a number of times. In other cases, in fact, we cannot conceive how the
circle can be thickened, contracted, and indurated so as to interrupt the passage
of intestinal matters. It is known by the mobility of the peritoneal prolonga-
tion, whicli is pushed back in drawing the intestine towards the abdomen by
the freedom of the ring, notwithstanding the constriction of the viscera, and
by the facility of introducing the finger completely or in part between the
fibrous circle and the root of the sac. If the strangulation is formed by the
external orifice of the herniary canal, the nail carried on this point will soon
give assurance of the fact. When more deeply situated, on the contrary, the
opening in question is neither tense nor completely filled. In this ease, it
will be known that the entrance of the serous membrane is not the cause,
but rather that of the aponeurotic canal, if the incomplete reduction of the
intestine is not accompanied with a gliding of the sac.
Two different methods have been proposed for removing the stricture,
dilatdtion and iiicision. The former was extolled by Thevenin, and afterwards
by Arnaud, and has been especially recommended by Leblanc. Various
instruments have deen devised to accomplish it. The double gorget, the two
branches of which open and close in the manner of dressing forceps, will,
certainly fuUfil the intention better than any crotchets or dilators that have
been contrived, if the method itself deserved to be retained ; but the only
advantage it presents, that of defending the vessels from lesion, iS' of too
little value in comparison with its disadvantage to allow its general adoption.
The impossibility of applying it when the strangulation is carried very far,
its insufficiency in the greater number of cases, the contusion of the viscera which
most frequently results from it, the enlargement of the ring instead of its
definitive closure, which will almost necessarily be the consequence, sufficiently
justify, in my opinion, the neglect into which it has fallen; and I doubt
whether M. Truestedst, who, alarmed by the fear of opening the arteries in
removing the stricture, has just proposed it anew, will find many imitators
among his contemporaries.
Incision or debridement consists in dividing more or less deeply, on one pr
several points, the free edge of tlie constricting circle. This is the delicate
and dangerous part of the operation. It exposes the organs within the ring
to be wounded, and even those still contained in the abdomen, but especially
the vessels on the contour of the hernia. On this account a host of diff*erent
pi'ocesses have been advised for executing it. The scissors curved on the
OPJBRATIVE SURGERY. 569
edge, formerly used by some, are proscribed at present and deservedly. It
is the same with the bistoury of Bienaise, an instrument which seems to have
given the idea of the. lithotome of Frere Come. The concave bistoury of Pott,
^now supersedes all other herniary bistouries. Sir A. Cooper has so modified
it^^.nat its cutting edge is not more than six or eight lines in extent, and stops
'^'within two or three lines of its buttoned extremity. Thus constructed, it
renders less liable to lesion the parts which during the cutting of the stricture
come before its heel. This trifling advantage should be accepted, but we
should be cautious in exaggerating its value, as has been done by some of our
masters, no doubt from want of reflection. I will remark here, that in certain
cases when the edges of the abdominal opening are very thick, when move-
ments backwards and forwards, or sawing movements become necessary, it is
less convenient than the bistoury of Pott. The oval plate which M. Chaumas
placed on its convex edge, in order to protect the intestines, is too much in
the way and of too little use to require further mention. The intention of
M. Dupuytren in transferring the cutting edge to the convexity, which seems
not to have been exactly understood by those who have v/ritten since, was to
render it better adapted to the division of the tissues, from before backwards,
and from the centre of the ring towards its circumference. Hence it is
suitable only in some cases, and we shall soon show that even in these cases
the simple straight bistoury, or the ordinary convex bistoury, may be used
advantgeously in its stead. The probe-pointed bistoury, edged like a file,
invented by J. L. Petit, is too coarse to divide the vessels, but will be fine enough
to destroy the continuity of an aponeurotic circle, but is of no value notwith-
standing all the eulogies that have been heaped upon it. The stricture is not
always caused by the fibrous tissues, and it is not proved that an instrument
just capable of cutting an albugineous circle will always spare the tissue of
an artery. As to the common probe-pointed bistoury, it is evidently less
convenient than the curved bistoury, as we are almost always obliged to follow
a passage more or less tortuous to come at and remove the stricture.
The winged director of Merry which the invention of M. Chaumas should
render useless, and which was intended to fullfil the same indication, is no
longer found in the apparatus of surgery ; so that Pott's bistoury is in reality
the only particular instrument that has been retained for relaxing the stricture
in strangulated hernia. When there are no vessels in danger, the concave
bistoury or even the probe-pointed bistoury, if a ring and not a canal is to be
acted upon, sufBces and may be preferred. The nail of the left index finger
is first introduced between the intestine and the circle to be divided, its pulp
then serves as a guide to the instrument of Pott, the bottom of which is carried
into the abdomen before turning its edge upon the resisting border. An assist-
a.nt then takes charge of the viscera, and separates them from the point to be
divided; another assistant acts in the same manner with respect to the lips
of the wound; after which the surgeon, combining the movements of his right
hand which holds the handle of the bistoury with those of the left index fin-
ger which supports its back, saws the ring until it yields and is decidedly cut,
which is told by a sound similar to the breaking of tin or the rumpling of
pacchment. However, as this noise comes from the fibrous tissue which is
br^cn;'it would be useless to expect it when the unbridling cut acts only on
the neck of the sac. Supposing the director is to be used, it will be as a sub-
72 "■
570 NEW ELEMENTS OF
stitute for the index finger; that is, after it has been introduced into the peri-
toneum the bistoury is passed upon it, and thus supported during the cutting
of the stricture. In such cases it is well for it to have a cul-de- sac to serve
as a limit to the point of the cutting instrument, and to have it curved so that
the concavity of its beak may be well applied against the internal face of the ^
abdominal wall, and prevent any portion of the viscera from coming between,
and running the risk of being divided at the same time with the edge of the
herniary opening. If it is absolutely necessary to be content with a straight
or sharp-pointed bistoury, all these precautions no doubt have their value ;
but with Pott's, or any probe-pointed bistoury, where can be its importance ?
Are they not more embarrassing than really useful ? To preserve with cer-
tainty the vessels about the neck of the sac, Bell has recommended a very
ingenious process, which is this ; a convex or broad -pointed bistoury, as most
of the English ones are, with its back against the pulp of the left index finger,
is carried in front of the ring and divides it at short strokes, fibre by fibre,
from below upwards, or from the centre towards the circumference, and from
its cutaneous face towards its peritoneal, taking care that the edge of the nail
always goes a little beyond the point of the instrument. The strangulation
is thus removed before arriving at the fascia propria, which contains tbe arte-
rial canals, and nothing forbids the incision to be carried to all proper extent.
It was evidently to obtain an analogous result that M. Dupuytren proposed
his curved bistoury with the edge on the convexity. This process, the advan-
tages of which I attempted to demonstrate in 1825, which M.Colson, and M.
Dellouey have introduced again as belonging to themselves, is in the first
place only adapted to a strangulation foreign to the neck of the sac ; secondly,
it would be impossible or dangerous to have recourse to it when the circle to
be divided is deeply situated or not well determined. For the rest, the most
common convex or slender-pointed bistoury will answer the purpose equally
as well as the bistoury of Bell. Moreover, the danger of wounding the ves-
sels is much less than is generally imagined. Enveloped in cellular substance
which lines the peritoneum and separates it from the fascia iransversalis or
the abdominal parietes, they are constantly thrown outwards, two lines at
least, upon the posterior face of the ring, and this is because the entrance of
-every hernia is widened into the shape of a funnel, and by entering it the vis-
cera themselves separate more or less the vessels. On the other hand they
are so flexible and generally so movable as to recede from the bistoury when
it touches them, rather than remain and be divided by it. When the stran-
gulation occupies a canal, and is not located at its posterior part, the neces-
sity of carrying the point of the instrument into the abdomen is not evident,
nor consequently is it evident in what consists the danger of wounding the
blood vessels. In fact there is another means of braving every inconvenience
of this sort with almost complete security when we are obliged to pass through
the whole of the herniary passage. This consists in making two, three, four,
five, and even ten incisions, instead of one, upon the dense margin which
binds the viscera. By thus multiplying them we can give to each but a line
or a line and a half of depth ; the enlargement of the orifice will yet be con-
siderable, and the vessels will be absolutely out of danger. The idea of this
process, which I shall call the '* debridement midtiple,^^ is already found in
Scarpa, and has long since received its application in vaginal hysterotomy.
OPERATIVE SURGERY. 571
M. Manche of Lyons published it in 1826. It seems that M. Dupuytren
adopts it also in some cases. But it was by M. Vidal (of Cassis) that it was
erected into a rule in 1827, and 1831, at the same time that M. Dellouey who,
no doubt by mistake, gives the honor of it to M. Amussat, proposed to com-
bine it with the method of Bell. For my own part, I have performed it three
times, and am led to believe that it deserves the serious attention of the ope-
rating surgeon.
JViiat extent should be given to the debridement ? If we trust some authors,
two or three lines will be sufficient. According to them, a more extensive
incision, by enlarging the ring too much, will most assuredly cause a relapse,
even when no wound of the vessels is apprehended. No doubt we should be
content with a small incision when the constriction is trifling and the reduction
does not require more. On the contrary if there seems to be a necessity for a
larger incision, the practice of Sharp, of Hey, of M. Dupuytren, and the
observations recently published by M. Janson, prove that there is no reason
for abstaining from it. The incision of two lines in extent, repeated in several
places, the debridement multiple will leave no excuse on this point to those
whom the vicinity of important vessels might deter. As to relaxation of the
herniary opening, it does not appear how it can be very formidable, unless on
the supposition that it is one of those long gashes which cannot be indispen-
sable except in some rare cases of deep strangulation. If the wound suppurate,
as it almost always does, the inodular tissue which is formed in front, or
even in the centre of the ring, to constitute the cicatrix, frequently offers to
the viscera a more powerful resistance than could have been presented by the
natural tissues. In this point of view the debridement midtiple should still
obtain the preference, because the more numerous the scarifications of the ring
the more solid will the cicatrix become, and the greater will be the chance of
seeing the elastic tissue in question developed.
Some authors have also thought, that it would be advantageous and possible
to remove the stricture without opening the sac ; that thus there would be an
operation attended with very little danger, as the peritoneum remaining intact
would not be so exposed to the inflammation which is so frequent after the
common operation ; that the viscera would by this mode be out of danger of
being wounded ; in a word, the opening of the sac, which is ordinarily attended
with so much uncertainty would be avoided, and celotomy performed with
confidence, promptitude, and very little pain. Of itself the cutting of the
stricture thus presents no more difl&culty in this way than the ordinary process.
The bistoury is introduced between the fibrous ring and the neck of the sac
instead of being passed between the sac and the viscera; the root of the hernia
is insulated with a little more care, in order the better to distinguish the
external face of the serous prolongation at its exit from the abdominal aperture,
and this is all. J. L. Petit, who set himself up as the defender of this mode
of operating, to which Franco, Rousset, Pare, and some others, had already
called the attention of practitioners, attributes to it, as has since been done by
Garengeot and Ravaton, so many advantages that no other would at present
be followed if they were real and not counterbalanced by still niore numerous
disadvantages. It is time in my opinion to cease to attribute to the contact
of the air, dangers which are so often encountered without any plausible
reference to such a cause. The radical cure which is pretended to be thus
57Z NEW ELEMENTS OF
obtained, is certainly less probable than by the opening of the sac. If the
hernia is reduced without dividing its peritoneal covering, it does not appear
how the obliteration of the passage is a necessary consequence, as it is main-
tained to be by J. L. Petit. It is to be feared that the parts contained in the
the sac may be the seat of alterations, which it is important not to mistake.
To what accidents will the patient not be exposed if the intestine be gan-
grenous, ulcerated, contracted, twisted, strangulated by a band, passed through
an opening in the epiploon, or if several of its parts adhere together. It is
evident, moreover, that in case of adhesion, reduction would be altogether
impossible, and that this species of liberation would be insufficient, whenever
the stricture is caused by the neck of the sac. Add to this, the serosity more
or less turbid of a deeper or lighter red, which may be found in the hernia to
the amount of several ounces or even pounds, as has been noticed above, could
not be returned into the abdomen without creating apprehensions. This
method, which may perhaps be successfully put in practice, for recent and
small hernias, presents therefore no real advantage over the ordinary method,
and deserves the neglect into which it has sunk, notwithstanding the successes
brought forward in its support in the name of M. Beau chene and of some other
modern practitioners, who seem to consider it of their own invention. Another
species of debridement, which seems to be as old as Franco, is that advised by
Pigray. It consists in making an incision in the abdominal parietes a little
above the strangulation, so as to be able by introducing the fingers into the
wound, to draw back the intestine and return it into the abdomen. Rousset who
wrote a little before Pigray, says that this mode had been followed by Duval and
his son, as well as by Maupas. Heister who refers it to Cheselden, is evidently
mistaken on this point, as Sabatier judiciously remarks ; the process of the
English surgeon appears to be the common one, but with a very large incision.
It is sufficient, I think, to mention the operation spoken of, to show its dangers
and absurdity. If after incising the anterior ring of the herniary canal there
be any difficulty in the reduction, it will be necessary to explore this canal
with the finger, and see that no second strangulation exist on die side of the
abdomen. If in this case the stricture depend upon the sac, we may, by
drawing the two lips of its external division, bring it in the wound and divide
it without danger, with blunt scissors or a bistoury, to any necessary extent.
"When on the contrary this posterior strangulation is caused by a fibrous circle,
the drawing out of the neck of the sac will be insufficient ; the curved bistoury
must be introduced, guided by the finger or a director, and be used as in
external strangulation.
Sixth Stage. — The obstacle which opposes the return of the displaced organ
being overcome, the next thing to be attented to is the reduction. After
spreading equally all the matters contained in the intestine which is visible,
the surgeon grasps it with the thumb and the first two fingers near the ring;
the right hand embraces the portion last issued and pushes it back, passing it
between the fingers of the left, which prevents its return, while a new portion
is seized and reduced in the same manner, and so in succession until the
whole is returned into the abdomen. The fore finger is then carried into the
canal, to be certain that the intestine has resumed its natural place, that it has
not turned through the substance of the abdominal parietes, that the sac has not
followed it, and tliatit is really free from all stricture or adhesions capable of
OPERATIVE 'SURGERY. 575
interrupting its functions. When there remains a strangulation at the pos-
terior part of the sac, whicli has formed but very feeble connections with the
parts adjacent, if the hernia is not very voluminous, it may return en masse,
by pushing before it the circle which strangulates it. Le Dran was one of the
first to point out this fact, which has been taught by many surgeons since.
The intestines then glide between the peritoneum and the parietes of the ab-
domen, sometimes are arrested there and become fixed. The stricture not
being destroyed a fissure is at length made, and then follows an effusion into
the abdomen. Arnault, De la Faye, Leblanc, Bell, and Sabatier have observed
cases of this description, and M. Dupuytren seems to have met with several.
It is not always in consequence of resistance of the neck of the sac that the
hernia thus returns without ceasing to be strangulated. If the strangulation
is situated at the internal aperture of the canal, and has not been removed, the
intestines may also be engaged between the fascia transversalis and the mus-
cles, separating these parts, and remain there quite as well as it might between
the aponeurosis and the peritoneum. An adult, twenty-eight years old, upon
whom I operated for an enterocele, presented this peculiarity, in 1823, at the
hospital of Improvement. After freeing the external aperture of the canal,
I forgot to explore the posterior ring, and passed to the reduction. As I had
heard no gafgouillement, and as the abdominal wall remained projecting, I de-
termined to carry my finger as far as the interior of the peritoneum, and then
discovered that the reduction was incomplete. The intestines were brought
out again ; and the left index finger carried to the bottom of the wound, soon
afforded me the certainty of a second strangulation, which was produced by the
inner ring. I removed the stricture, and the reduction presented no further
difficulty.
It is therefore necessary to distinguish the return of the intestines between
the peritoneum and the aponeurosis, from that which takes place between the
aponeurosis and the muscles, or the different muscular layers of the abdomen,
and not to confound the obstacle depending on the neck of the sac with that
which arises from a stricture in the posterior ring. When such an acci-
dent happens, the first thing to do is to reproduce the hernia. This is accom-
plished by directing the patient to cough, to bear down, and even to get up. —
Frequently however the viscera come out again spontaneously. When they
can be reached with the finger it is still better to take hold of them and draw
them outwards, using all proper precautions. If the difficulty arises from
the neck of the sac, 'tractions upon the portion of this covering which remains
in the wound will frequently prove an excellent means of attaining the end
proposed, as has been proved long since by M. Dupuytren. However, neither
of these resources will constantly insure success. Chopart, Lobstein, and
other experienced practitioners have seen their patient sink for want of this
reproducing of the hernia. There is another circumstance which sometimes
opposes to the immediate return of the organs into the abdomen; it is the
case in an old and voluminous hernia. Having accomplished the reduction
of a tumor of this kind with much difficulty and fatigue, J. L. Petit found the
symptoms to continue, and only cease when the viscera were permitted to
descend. He explains the fact, by saying that the abdominal cavity was
accustomed to the absence of the organs ; and so contracted as no longer to
allow them admission, so that thev had lost as it were the right of domicile.
574 NEW ELEMENTS OF
When the extensibility of the parietes of the abdomen is considered, when in
the same day they permit the stomach and other entrails to acquire double or
triple the dimensions they previously had, it is difficult to believe that their
resistance alone is of a nature to render the reduction of any hernia impossible
or dangerous. Is it not more probable that in the environs of the neck of an
old and voluminous hernia, adhesions are established between the organs so
as to render their displacement difficult, or rather that the viscera being a
long time displaced cause unpleasant symptoms to occur, because after the
reduction they remain compressed, agglomerated, united into a mass, and do
not freely spread behind the ring ? This reflection, which long since occurred
to me, which has also been -wiade by M. Curveilhier, and which Petit the
younger does not forget, deserves in my opinion some notice. For the rest
we should not go so far as to deny absolutely the explanation of J. L. Petit,
which really applies to young and vigorous subjects whose abdominal parietes
are endowed with great elasticity, and are of considerable thickness, to those
of a certain embonpoint, and in whom the epiploon is loaded with fat. On the
■whole, it would be better to leave the intestines within the sac after freely
incising the stricture, than to bruise and injure them by attempting their
reduction. Experience has shown, that being thus kept without they in the
end insensibly return, if not entirely at least for the greatest part. The hori-
zontal posture, the debilitating regimen to which the patient is confined, creates
by degrees in the abdomen a kind of void, which singularly promotes the
effect intended. Before declining the reduction we should give it a second
examination. There are a number of alterations for which the return of the
parts into the abdomen would indisputably be the best remedy. Thus con-
centric ulceration should not prevent it, if confined to the external membrane
or even to the muscular coat ; if in a word, it does not completely perforate
the intestine. A coarctation of the displaced organ is not always a counter-
indication. If it be recent and moderate, leaving to the alimentary canal
at least half of its natural dimensions, it maybe expected finally to disappear,
and the cure will probably be advanced by replacing in the abdomen.
Gangrene is a condition which most decidedly opposes every attempt at reduc-
tion. But for the same reason we must not be deceived by appearances. If
the strangulation is acute, and there has been inflammation, and the symptoms
have lasted sometime, the intestine contained in the hernia is more or less
red. Frequently it is found of a dark or greyish brown, with the peritoneal
coat separable in small flakes, having lost its smooth and moist appearance
and become wrinkled, and all this without the existence of gangrene. The
fetid odor or presence of fecal matter which some persons have given as
characteristic signs, may also occasion mistakes. The same remark applies to
the slate-like, or grey cinereous tint. If its tunics are not sunken, flaccid,
and folded as it were upon themselves, if it resists the tractions made upon it,
if it remains dense and shining, if the thickness of its parietes seems to be
increased instead of diminished, if it preserves some warmth, and this warmth
remains equal on every point after being exposed sometime to the air, if it is
not the seat of any perforation, there is no gangrene. When intimate adhe-
sions, which cannot be destroyed, are encountered, it is not the less neces-
sary to make the debridement as in ordinary cases, only it is proper to make
it a little larger in order afterwards to return the free portion of the viscera.
OPERATIVE SURGERY. 575
The rest is left in the sac, which is covered with compresses soaked in some
bland fluid, as in the case of large irreducible hernia. When freed from the
constiiction ot these parts, the organs, being drawn upon by those of which they
are a continuation, often in the end return of themselves, or at least form
within the ring but a small tumor, which a concave pad will easily support
after the cure.
B. Epiplocele. — We have as yet scarcely noticed any but intestinal hernia.
Epiplocele existing by itself is rarely so strangulated as to require a removal
of the stricture, but it is very common to find in the same sac a. loop of in-
testine and some considerable portion of epiploon. In this case it is proper,
before cutting the stricture, to see if the opening has not contracted a union
with the neck of the sac or around the intestine. It is also proper to make
the incision on a point not occupied by the epiploon, so as not to expose to
division any of the vessels, sometimes very large, which run through this ex-
pansion! Although it usually presents first on opening the sac, yet the reduc-
tion must begin with the intestine after the removal of the strangulation.
That of the epiploon is always more difficult. It has almost always under-
gone some alteration. If it should be fixed in the sac only by bands and
filaments it would be very easy to destroy them. When its adhesions are inti-
mate and lamellated it becomes almost indispensable to remove the part. If
it have remained long displaced it has become loaded with fat, or transformed
into an adipose mass, or reflected upon itself, giving rise to knots, cylinders,
and hard shining tumors which have been compared to scirrhus. But a
great variety of forms are met with, and it would be almost as impossible as
useless to describe them all. If these masses were reduced with the vis-
cera, when they are susceptible of this reduction we might expect that some of
them would be resolved, but this would rarely occur ; and should they be of any
size their presence in the abdomen would be attended with too much danger to
allow of the attempt. Excision is without danger when they are peduncu-
lous, as often happens, and when we are not obliged to cut ii^o the sound
portion of the epiploon. In the month of April last, M. Payer and myself
cut down to an entero-epiplocele in which several of these productions were
developed. One, four inches long and from fifteen to twenty-eight lines
thick, adhered to the fundus of the sac by an epiploic band, still distinguish-
able, and was continuous towards the abdomen with the same membrane, by a
narrow lamella of so little vascularity that it was divided without the least
flow of blood. Another not so long but more enlarged about its middle,
which had also a broad root, was removed in the same manner with no more
inconvenience. Besides, if their root appears to contain vessels of a certain
calibre, nothing prevents their being encircled by a double ligature before
removal. Should the epiploon preserve its natural state it is to be reduced,
if its return into the abdomen is not attended with too much difficulty. With
this intention it is pushed back by degrees, commencing, as far as the intestine,
with the part last come out, after it has been freed from all adhesion and
every kind of duplicature. When it is irreducible some contend that it
should be left in the wound, that it will return little by little, and that a con-
cave pad will support very well the part that may remain without. Excision,
which is at first view quicker and more satisfactory, has not as yet been
adopted but by a small number of practitioners. There are three modes of
576 NEW ELEMENTS OF
:W . .
performing it ; first, to cut between the dead and living parts in case of gan-
grene ; second, to cut in the living part whether there be gangrene or not,
to use no ligature, and reduce it ; third, to cut in the living portion and tie sepa-
rately the vessels as they spring. The first method is bad; because if any
mortified tissues remain, their return into the abdomen could not fail to be
dangerous, and if the bistoury touch upon the yet living tissues a hemorrhage
might be the consequence. The second has been defended by Caque of
Rheims, who gives nine successful cases in its favor. With this author I am
convinced that ligature of the epiploic vessels is not always indispensable, and
that often they will cease to bleed after a certain time. Nevertheless I
would not dare to propose his practice as an example to be followed. I con-
formed to it once with a patient of M. Florence. Until then the operation
presented nothing peculiar. It was necessary to remove a part of the epi-
ploon. The vessels at first scarcely bled at all. I made the reduction, and
in the night a quantity of blood flowed from the wound. Syncope, and
llpothymia accompanied with cold sweats supervened, and although the vomit-
ing had ceased and the matters resumed their natural course, the woman
died ten hours after the operation. This was sufficient to make me resolve
not to run the same risk in future. The third is the mode followed by M.
Boyer. To perform it, the surgeon begins by displaying and unfolding the
epiploon, so as to have but one membrane to divide ; he then cuts off with the
scissors or bistoury all he intends to remove, seizing each vessel as it springs
with the forceps, and tying it immediately. This done nothing remains but to
push the preserved parts behind the ring, and bring all the ends of the
ligature together to one of the sides of the wound. The disadvantages of this
operation are, the time required, the minute search for the vascular canals, and
the probability of omitting some of them, which in the end may give rise to
danger. This is however the most worthy of confidence, and indeed the
only one that ought to be adopted when it has been decided that nothing is to
be left in the wound, and the parts are to be entirely reduced. In this case
however it would be proper to introduce an important modification. The liga-
tures, in fact, will not permit the epiploon to be left behind the heniary
opening, but will oblige it to be left in the wound. Torsion of the arteries,
which is easily performed in this case, would supply their place advantage-
ously, and ought to be substituted. I have twice employed it, and I think that
without it my operation would have been less simple.
The ligature, for a long time in use, mentioned even by Galen, has during
the last century been the object of numerous attacks. J. L. Petit among
others accuses it of causing dreadful dangers. A patient thus treated was
immediately seized with colic, violent pains in the abdomen, and nervous
symptoms; and it was not known to what to refer them. The surgeon
renioved the dressing to see if the intestine had not redescended. Finding
nothing of this sort he took away the ligature, and all the symptoms vanished
as by enchantment. From this and other facts it was concluded that stricture
of the epiploon was almost as formidable as that of the intestine. Theory,
always ready to come to the support of suppositions arising from practice,
seemed to account for the phenomenon, by snowing that the great sympathetic
nerve distributes a certain number of filaments over the whole pxtent of the
epiploic expansion Pipelet says, that the danger arose only from the con-
OPERA^TIVE SURGERY. 577
sjtriction rolling into a cord a membrane that should remain expanded, and
the opinion of J. L. Petit has thus passed into an axiom. However, as the
ligature is much more convenient, and more easy of application, and protects
from hemorrhage quite as certainly as any other mode, some practitioners
have not been willing to renounce it entirely. Hey, for example, and Scarpa
maintain that they removed its inconveniences, without destroying its ad-
vantages by means. of a very simple modification ; the first applied the ligature
after the manner of the ancients, but tightened it only by degrees so as to
strangulate and produce mortification of the organ only after several days,
instead of suddenly intercepting the circulation; the second leaves the
epiploic tampon in place until it is covered with cellular granulations, and
then strangulates it after the manner of Hey. The cases reported by these
authors in favor of their practice prove its harmlessness, and leave no doubt
that, it ought to be preferred if the ligature en masse is to be dreaded as much
as Petit imagines. Happily it is not so, and on this point we may appeal to
the judgment of the academy of Surgery. I have already had occasion to tie
the epiploon four times, and the four patients got well without any serious
symptoms. When the tumor to be removed does not exceed the size of the
finger, it may in my opinion be included without fear in a strong ligature, and
completely strangulated at some distance from the ring. On the contrary,
when it is larger the root may be divided into as many portions as desired, so
^s to admit a ligature about each separately. Two were sufficient in the case
of a woman on whom I operated in 1829 at Saint Antoine. It was the same
in the case of a man operated upon this year (1832) by M . Pay en. Quite
recently, the 8th August 1831, seven were necessary in the case of a woman
upon whom I operated in conjunction with M. Gresely. All without the
ligatures is then cut oflf, and the ends of the ligatures are brought together on
one or more points of the circumference of the ring, and the operation closes.
To sum up these remarks, if the epiploon is gangrenous, and it is desired to
return the sound part into the abdomen, it is best to cut in the living portion
and twist the arteries. If the surgeon thinks proper, on the ccmtrary, not to
return it beyond the herniary circle, he may confine himself to the separation
of tlie completely mortified parts without using either the ligature or torsion.
When it is simply irreducible and still possessed of vitality, and we are
obliged to excise it and then keep the rest within the ring, one ligature in-
cluding the whole, or several embracing each a distinct portion, present the
process at once the most simple and the most prudent that can be followed.
On this subject a question arises. Is it better, everything else being equal,
to retain in the ring the epiploon from which the excision has just been made,
or to leave it in the abdomen ? Fixed in the passage of the viscera, it would
contract adhesions, vegetate, become covered with cellular granulations,
harden by degrees, and finally blend itself with the cicatrix, so as to render
a return of the hernia almost impossible. If returned into the abdomen, it'
leaves the opening through which it passed entirely free, and in no respect
increases the chances of a radical cure. Two motives have prevented the
exclusive adoption of the first line of conduct, 1. It has been argue'd, that tlie
epiploon being once reduced should remain perfectly free, and oppose no ob-
stacle to the various motions of the digestive organs ; 2d. an apprehension
has been felt that the epiploic expansion might drag painfully and even
57^ NEW ELEMENTS OF
dangerously on some of the viscera, and that thus stretched by its two
extremities, it might constitute a band or budge, which could become the cause
of internal strangulation. A single remark destroys the whole force of these
reasons. When it has been returned into the cavity of the abdomen, the
bleeding portion of the epiploon neither remains free nor floating: on the
contrary it invariably unites with some point of the surface of the peritoneum,
so as to induce the same danger as if it had its j^oifit d^appui in the ring. I
think, therefore, that after excision it would always be proper to retain its
extremity in the wound. It has at least this advantage, that it is one of the
most certain means of obtaining the radical cure of hernia. A number of
surgeons go so far as to act in this manner whenever the epiploon, reducible
or not, is found in the sac. In reducing it they preserve a pad or kind of
stopper which closes the summit of the wound. I have it from Dr. Stevens,
the able professor of New York, that he long since adopted this method, and
by it has obtained much success. In my opinion, however, prudence does
not authorize the practice where the reduction is easy and all the parts are
sound. The formation of a band or abnormal septum in the interior of the-
abdomen is never justifiable when it may be dispensed with, and the fear of
bringing on internal strangulation should evidently prevail over the desire of
obviating the necessity of a bandage.
Some practitioners have thought that after the return of the whole of the
viscera, the sac remaining in the wound should in its turn occupy the attention.
Those who with Garengeot direct it to be set free without opening it, thought
to insulate it entirely, and agglomerate it in the interior of the ring, where it
should be fixed by a pad of lint or charpie. Others have advised to pass a
ligature over its neck to strangulate and then excise it. Even in cases where
it has been opened in the whole of its length, it was thought possible to reduce
it and use it for closing the passage of the hernia. Louis was strongly
opposed to all these attempts, maintaining that the reduction of the sac was
impossible, and that the adhesions of its external face did not permit the
sliding necessary for its accomplishment. On this point Louis was assuredly
mistaken, at present there is no doubt on the subject. On the other hand it
is extremely probable that being thus pushed back, opened or otherwise, the sac
would close the ring firmly enough to present an obstacle to the return of the
disease. Excision or ligature would not have the same advantages though
exposing to the same inconveniences. If it is necessary in effect, for obtaining
its separation, to have recourse to the cutting instrument, there is evidently a
risk in some cases at least of wounding bloodvessels or other organs important
to be respected. I would advise, therefore, the reduction of the sac whenever
it is found almost free, or when its adhesions are weak enough to be broken
down without the aid of the knife. It has been thought beside, that after it
has been once opened, if we would not or cannot reduce it, it would be useful
to cut away its flaps. To this I see no objection, except that it is not ap-
plicable to hernias surrounded with large arteries or organs of any import-
ance. Nevertheless if the borders of the sac are so perfectly insulated as to
render it certain that they may be excised without wounding any essential
part, I sec nothing but advantage in doing so. In this way the wound is
neater, the suppuration less abundant, and the remainder of the operation be-
comes necessarily a little more simple.
OPERATIVE SURGERY. 579
C. Dressings.— The dressing after the operation is reduced to a small mat-
ter. A linen rag perforated with holes and spread with cerate is placed over
the whole of the new surface. Rolls of simple charpie intended to push this
linen to the very bottom of the wound are immediately applied over it. Some
dossils of lint then follow with oblong or square compresses, and lastly a
bandage adapted to the species of the hernia. Instead of the perforated rag
some use a fine linen, without any other preparation Being larger than the
wound it serves as a kind of chemise to the charpie, and fullfils moreover the
some intention as if it were perforated, but as it does not allow an issue to the
fluids, I see no reason for preferring it. Others merely fill the whole open-
ing with msall balls of charpie without interposing the linen, and cover it with
dossils of lint, compresses, and the retaining bandage as before. The principal
inconvenience in this practice is that it renders the removal of the deeper por-
tions of the apparatus more difficult after the first dressing. Being in immediate
contact with the tissues the charpie contracts adhesions, which suppuration
does not destroy until after some time, while if a perforated linen separate them
we may change and renew all the dressing as well on the second and third day
as on the first without giving the least pain. For the rest, nothing is said at
the present day of keeping a tent in the ring, nor of keeping in its place a pad
of linen or charpie as directed by J. L.. Petit. There is now no dissent on
this subject, and operators are no longer divided except on the question of im-
mediate union. Franco, who appears to be the first to have attempted to es-
tablish as a rule the necessity of exposing the hernia and cutting the stricture
in case of strangulation, advises that the edges of the wound be approximated
and the suture used to keep them in contact. The greater number of sur-
geons of that time seemed to have conformed to the advice of Franco. There
were none, even to Rousset, Pare, Pigray, and Thevenin, who had not adopted
it. It had fallen into neglect however, when about the middle of the last
century Mertrud attempted its introduction a secone time, maintaining that
the wound in this operation is in the same condition as a simple wound. Not-
withstanding the I'easoning of Hoin and Leblanc, who adduced a number of
facts in its support, it at length fell again into disuetude, as in the age in
which it arose. Immediate union however appears to have been attempted by
some modern practitioners. The work of Doctor Serre proves beyond dispute
that it is in effect possible, by means of the suture, to heal in a few days the
wound resulting from the operation for strangulated hernia, and that his able
preceptor frequently employed it with success. Professor Berard informed
me that he tried it at the hospital St. Antoine, and that his patient got well in
six days. On this subject all that is required in my opinion is merely the
correct understanding of it If question is only of the possibility of the thing
no doubt that the practitioner of Montpellier is entirely right, but it is the
utility of this proceeding which is to be examined. When the hernia is not
large, is recent, and its coverings preserve a certain thickness and nearly all
their natural attributes, when the sac does not roll nor leave fringes nor
shreds to mortify at the bottom of the wound, immediate union may certainly
take place in a large proportion of cases. When the tumor has been of
larger size, and its covering, more or less attenuated, have become the seat
of various alterations, when the sac is quite large and tends to roll upon itself
the reduction of viscera, tiie chance of success is not so great. In this case
580 NEW ELEMENTS OF
it is to be feared that suppuration may be established in the depths of the
parts and separate them, to spread in various directions, and cause sinuses,
and consequently a state of things that may become very serious. This
occurred in the only case in which it appeared to me prudent to attempt im-
mediate union. The hernia was not very large, and the lips of the wound
exactly adapted were supported towards their root by an exact and methodical
compression. It appeared oiji the fifth day that agglutination had taken
place. But on the next we were undeceived. Swelling, redness, pain, and
heat were manifested beneath one of the sides of the division ; the inflamma-
tion increased, and was accompanied with fever and other general symptoms,
which only abated after the opening of a large abscess which was obscurely
developed about the inferior angle of the sac. Besides, this immediate union
seems to me to conflict with one of the intentions of the surgeon ; which should
be, to favor as much as possible the radical cure of the disease. If it is in-
contestable, that the solidity of the cicatrix is greater the longer the wound
lias suppurated, it is evident that after the operation for hernia, patients have
more chances of being radically cured when union of the wound is obtained
by second intention than in the contrary case. We may add, that without
bringing the divided tissues into perfect contact, it is easy to approximate
them a little, and diminish more or less the extent of the raw surfaces, and
by keeping up the suppuration obtain a cure in twenty or thirty days. A
patient upon whom I operated with M. Amussat, was treated in this manner
and his wound was completely closed on the twenty -fourth day. A woman
to whom I was called by M. Forget was also entirely restored at the expir
ration of a month. But I*am not sure that after this operation a more rapid
cure would be of as great importance as some persons seem to imagine. In
conclusion therefore, with some exceptions, mediate union offers the most ad-
vantages, and in this place deserves the preference.
The patient, once dressed, is directed to make no effort or motion which
may react on the abdominal organs, or if he is obliged to cough, or contract
his muscles for any purpose, to apply his hand in front of tlie apparatus to
support it. Without these precautions the intestine may escape again and
renew the symptoms. Lassus relates the case of a man who in this condition
had the imprudence to leap from his bed and walk several steps. The intes-
tines came out in great quantity, and then reduction was attended with great
difficulty. We must not permit ourselves however to be too much alarmed
by the fear of this accident. After being returned into the abdomen the intes-
tine does not protrude again as easily as may be supposed. A slight fit of
coughing, and the moderate efforts which the patient makes in turning himself
in bed are not sufficient to reproduce the hernia. If in consequence of the
debridement the orifice of the abdominal wall is a little larger than usual, the
sensibility already existing in the parts, or that which the inflammation soon
produces, forms a kind of barrier which the viscera rarely pass over. It
seems as if an instinct prevents them from pressing on this side, and even
when he has no tliought of it the patient is forced as it were if he makes any
movement to prevent it being propagated towards the wound. These remarks
appear to me useful, inasmuch as though from prudence we should prescribe
rest and immobility to the individual upon whom the operation has been perr
formed, yet there would be this inconvenience, that in not daring to move in one
i
OPERATIVE SURGERY. 581
way- nor another, he miglit consider the slightest movement dangerous. I
should also have said that there is no necessity for making the bandage com-
press the front of the wound, and that a retaining apparatus methodically
applied perfectly fulfills the end proposed.
D. Results and 7Ve«/?7ie/if.— Except in case of particular accidents the
wound should not be dressed until the third or fourth day. It is only about
this time that suppuration begins to be established. The dressing is then
renewed every day and has no peculiarity. If shreds of the sac, of the epi-
ploon, or any other lamellae, mortify, they are to be excised immediately.
Emollient lotions or chloruretted solutions, and perhaps the decoction of cin-
cona when the suppuration becomes fetid and greyish or the flesh remains
dull, and the use of the nitrate of silver if the cellular granulations are
developed too actively, may become necessary; but these various applications
are called for by the same indications as require them in any other species of
wound. When all goes on well, the symptoms of strangulation ceaee almost
immediately. Alvine evacuations are abundant after several hours, and greatly
relieve the patient. The pulse resumes strength, and sometimes acquires so
inuch frequency as to indicate a febrile condition, and only after four or five
days will this slight reaction permit us to relax the severity of regimen. Most
frequently the functions are not re-established so promptly or completely.
Inflammation of the peritoneum may extend instead of abating, or the course
of fecal matters may not be easily re-established. The superior portion of
the intestine may have been filled with substances more or less solid, which
keep it distended in comparison with that which has been constricted. The
peristaltic motion having besides been disturbed, sometimes resumes with
difficulty its habitual rhythm, and the fecal matters are therefore not pushed
downwards with sufficient force to arrive without obstacle at the inferior
extremity of the alimentary canal. This sluggishness of the intestine may
depend on the moderate inflammation of its several tunics which may have
occurred in the vicinity of the hernia. If therefore the stools are not
spontaneously re-established in two or three hours, a mild injection is to
be given. If this be not sufficient, another of more stimulating eiFects is
to be administered. If after twelve hours evacuations have not been pro-
duced, purgative enemata with the decoction of senna must be resorted to.
Many practitioners are in the habit of employing at the same time a slight
purgative administered by the mouth. Dionis, who insists much on the advan-
tage of this mode, says he received it from Moreau physician to the Daupliiness.
Some surgeons, at the head of whom must be placed Dupuytren and Mr.
Green, nevertheless condemn its use, by saying that it can only increase or
aggravate an inflammation already giving too much cause for apprehension in
individuals affected with strangulated hernia. At first view this reasoning
may deceive, although in fact it is easy of refutation. The truth is, that the
matters accumulated in the intestine are a, powerful cause of inflammation^
and the best mode of overcoming or preventing this inflammation is to oblige
them to escape by the rectum. In this light, purgative enemata and potions
of the same nature have an efficacy which cannot be doubted. At the hospital
of Tours, I have seen M. Gouraud operate for a great number of hernias ; to
all his patients a purgative clyster was administered almost immediately after,
and no vvhere to my knowledge has a greater proportion of success been
582 NEW ELEMENTS OF
obtained. M. Bojer, who seems to follow the same practice, has the reputation
of being very fortunate in this kind of operation. As to the nature of the
purgative it may be varied. Some give one or two ounces of castor oil in
spoonful doscii ; others the epsom salts. The dose that I prefer, because I
have seen it employed with great benefit, is composed of an ounce or two of
manna dissolved in a glassful of mint infusion. Some prefer this last article
in four ounces of red wine. Common opinion is against the use of this vehicle,
and for myself I have nothing to say in its favor. It is unnecessary to add
that the administration of a purgative is not called for, and is at least useless
when the stools occur spontaneously and no sign of intestinal embarrassment
is manifest.
When instead of simple obstruction symptoms of true inflammation are
remarked, or when peritonitis is threatened, notwithstanding the course of the
feces is re-established, the patient should without hesitation be subjected to
the most energetic antiphlogistic treatment. One or more bleedings from the
arm, one or more applications of leeches to the number of twenty, thirty, forty,
and even sixty, if the strength of the patient permit, in the course of twenty^
four hours, should be prescribed, if instead of decreasing the phlegmasia tends
on the contrary to extend and become general. I see no reason why the
mercurial treatment, mercurialization, should not have its turn ; why we should
not make every two or three hours friction on the abdomen with two or three
drams of Neapolitan ointment, giving at the same time two grains of calomel
eveiy two hours. The cases of puerperal, simple, and traumatic peritonitis,
which have evidently yielded to this treatment, sufficiently authorize its use
wlienever sanguineous evacuations give no further chance of success. Unfor-
tunately these are not the only obstacles which may oppose the re-establish-
ment of the functions after celotomy. Besides the return en masse of the
intestine which continues to be strangulated by the neck of the sac, or which
lodges in the substance of the abdominal parietes, it is also to be feared, lest
the loop which was without, pass in its return above or below an abnormal
band which is so often met with behind or around the herniary openings ; and of
which almost every author reports examples. It is also possible, tliat the
portion just reduced may make a bend or angle so acute as not to allow tlie
matters to pass through it, of which a case of Lassus gives instance. The
same difficulty may depend on the intestine being twisted so as entirely to
close its cavity. It may, moreover, have passed through a rent in the epiploon,
in some old false membrane or in the mesentery. In fine, if the vomiting, pain,
and distress continue with the constipation after the reduction of the viscera,
without these symptoms being referable to violent inflammation of the perito-
neum or some viscus, when there is no reason to suspect an effusion of intes-
tinal matter we are authorized to conclude that the strangulation still exists,
and from external has become internal. In this case the patient runs the
greatest risk, for ,with the exception of very few cases surgery has but feeble
aid to offer. However, we should try those that reason recommends. The first
indication is to bring out the hernia, as when the viscera have been returned,
pushing before them the neck of the sac. The patient is for this purpose made
to cou^i and move about; if unsuccessful, the finger should be carried through
the ring into tlie abdomen to discover as much as possible the state of things.
If the wxrgeon clearly distinguishes the intestinal loop, and finds it tense, fixed.
OPERATIVE SURGERY. 583
immovable, he will attempt to seize it with dressing forceps and bring it
without. If a band, a circle or any lamella seem to cause the stricture, he
should immediately divide it with scissors or the bistoury, directed by the finger.
If the finger cannot reach the parts, or only afibrds confused notions of their
disposition, the environs of the wound are to be examined with care, to see if
the organs contained in the abdomen form there no prominence or tumor
visible through the skin. There is no question that then in a desperate case
he should freely enlarge the incision of the ring, and penetrate as far as the
point occupied by the strangulated organs ; so as to bring them completely in
view, and be enabled to give them full liberty to spread within the abdomen*
§ 5. Gasirotomy.
The symptoms which characterize internal strangulation being due to the
inability of the intestinal matters to pass through their natural course, should
be altogether similar to those of incarcerated hernia. It seems then at first
view that this is easily recognized. We have on the one hand all the signs of
herniary strangulation,, and on the other a complete absence of swelling on the
surface of the body ; yet it some times happens that the diagnosis remains
uncertain. Notwithstanding the presence of an external hernia, it is not
impossible to mistake for external strangulation a disease entirely indepen-
dent of it. A partial peritonitis, an acute inflammatory tumor of the bottom
of the abdomen, and abscesses which are frequently developed in either iliac
fossa, have often been the cause of repeated vomitings, obstinate constipation,
and acute pain, upon a fixed and circumscribed point of the peritoneal cavity.
In fine, an almost insurmountable difficulty consists in distinguishing the obsta-
cle in question from organic lesion of the intestine, from volvulus, and from
strangulation proper. However, if the affection attacks suddenly upon a strain
or any violence whatever, if the patient has thought he perceived a tearing ac-
companied with crepitation and pain, propagated from a given point to the rest
of the abdomen, if from this moment vomiting first of alimentary and mucous
substances, and then of stercoraceous matters continues, while alvine evacua-
tions have become impossible, and the usual signs of violent peritonitis are
absent, it would be very difficult not to admit the existence of internal stran-
gulation. Three different methods have been proposed to remedy accidents of
this description. The old surgeons who were famous for suspecting invagi-
nations and twisting of the alimentary tube, had great confidence in quick-
silver, leaden bullets, purgatives, &c. They hoped by means of such heavy or
active substances to act mechanically upon the entrails, or force them to be-
come disengaged by means of precipitate movements. MM. Balluci, Bellini,
and Ribell have in our days brought out examples in favor of fluid mercury.
In recent and simple volvulus such resources may be followed sometimes with
success ; but there is no one who would not. be deterred from their use in
cases of internal strangulation. For my part I would not hazard the attempt.
Local and general bleeding, cataplasms, opiates, calculated to moderate
inflammation and ease pains, have no kind of influence over the state of stric-
ture in which tlie intestine is found. Their sole advantage lies in favoring the
efforts of the system and the action, by means of which it has been in certain
cases so fortunate as to re-establish the continuity of the intestine withoyt
effacing its calibre. The ivaginated intestinal portion, may in fact after a
584 NEW ELEMENTS OF
shorter or longer period and alarming symptoms, separate by the rupture o€
its neck, or of its root, whether from gangrene or the progress of simple, elimi-
native ulceration. Then the mortified mass becoming free passes through all
the inferior portion of the alimentary tube, and is in the end expelled. In
this manner have come away the caecum, a great portion of the sigmoid flexure
of the colon, and a considerable portion of small intestine, of which the me-
moir of Hevin contains numerous examples. MM. Rigal and Bourial.have
seen as much as thirty inches of the small intestine expelled by this mechanism.
Similar observations have been reported by MM. Mallet of Rouen, Bailie,
Lobstein, Lacoste, Boucher of Lille, Gualthier of Claubry, &c. Other facts no
less remarkable have been since collected and published in the Bulletins of
the Philomathic Society, and the society of the Faculty of Medicine, in many
theses, and most of the scientific journals.
It is easy to see that such a termination is not possible except in cases of
invagination, and that to destroy a real strangulation we cannot depend upon
the efforts of the system. Gastrotomy presents as the last resort. Up to the
present time but few persons have dared to perform it, and experience has in
some degree remained silent as to its value. We cannot, indeed, take any
count of the history of the Baroness of Lanti, mentioned by Bonnet, who
according to an ecclesiastic had been cured of an iliac passion by incision of
the lower belly. Although the case in which Nuck advised the abdomen to
be opened, in order to reach the intestines and set them free, is a little more
authentic, and although M. Fusch has shown latterally a case of gastrotomy
for invagination completely successful, we can yet rely only with extreme
reserve on this paucity of observations. However, if it happen that we have
a certainty almost complete of the existence either of a recent invagination or
of a strangulation, and that the location of the disease is well determined, we
ought, I think, to hazard the operation of gastrotomy, which was employed in
the time of Praxagoras who performed it, uniting the wound of the abdomen
immediately by the suture. M. Dupuytren, who tried it once, would probably
have succeeded if he could have cut as he wished on the side where the pain
was felt, instead of the linea alba according to the advice of the consulting
surgeons. One case at the hospital St. Antoine, proves also tl\at it is some-
times possible to tell exactly enough during life the precise seat of the
strangulation, and that Laennec was probably right in advising the epigastrium
to be opened in diaphragmatic hernias in order to remove the viscera from the
chest with the fingers. The patient should be placed as for the operatio'n of
ordinary hernia. The incision, better crescentic than straight, should be made
very near the strangulation. If we are not sure of the seat of this last, it is to
be made outside of the rectus muscle, and with the fingers we are then to seek
for the diseased portion. In a case of invagination the two ends of the intes-
tine are to be drawn in an opposite direction, and the whole immediately
replaced in the peritoneal cavity. If there is strangulation the finger will
doubtless detect it and insulate it, so that a curved bistoury wrapped with
linen to witliin several lines of its extremity, may divide without danger the
band or constricting circle. Another species of internal strangulation deserves
to be noticed ; it is that which occurs after the forced reduction of a hernia./
When it is caused by tiie neck of the sac, if the taxis is em^jloyed with any
viplence the tumor may return dragging with it its intimate covering. Then
it places itself between the parietal peritoneum and the deep aponeurosis of
OPERATIVE SURGERY. 585
the abdomen, precisely as it is observed in some cases of the operation for
strangulated hernia, properly so called. M. Delmas cites a case in which the
organs were thus arrested in the very substance of the muscles. They may
also pass beneath a band, or through a fissure in the same manner as in re-
ducing them after opening the sac, as I have already mentioned. It is
unfortunately too common a tiling to see these reductions en masse under the
influence of the taxis, offer no impediment to the progress of the symptonis.
There are few authors who have not collected examples, and they are still
daily met with in practice. If the symptoms only announce the continuation
of the strangulation, without indicating the existence of fecal effusion ; in
other words, if the intestine seem neither gangrenous nor broken, we should
not despair of the life of the patient, but attempt to give him assistance. The
first care is to bring out the hernia again. If nothing present at the ring, the
surgeon would be blameable to temporize too long, and refrain from performing
the operation immediately. He knows that a herniary tumor exists, that after
giving rise to symptoms or remaining for some time without, it has disappeared
suddenly under the influence of external efforts ; the opening which gave it
passage is free and easily admits the extremity of the finger, quite frequently
even presents a kind of depression or cul-de-sac, seems to be drawn inwards
by some band or adherent membrane ; sometimes also the finger introduced
into this depression feels at its bottom the intestinal tumor incompletely
reduced. In this Supposition the soft parts are to be incised as in ordinary
strangulated hernia, and by degrees we arrive at its interior. If the sac can
be reached, it is rare that the operator does not reach the seat of the disorder.
M. Dupuytren, who has been frequently called upon in this species of stran-
gulation, and, at the Hotel Dieu, has seen a great number of cases, remarks,
that after having vainly endeavored to bring out the viscera again, there
remains the resource of freely incising the ring in the direction in which there
are no vessels, and of arriving thus within the abdomen.
§ 6. Hernia loith Gangrene.
Gangrene, — When gangrene is evident the division of the tissues does not
require the same precautions as in the ordinary operation. The incisions in
fact may without danger penetrate at one stroke as far as the intestine. If
it affect all the tumor, and the hernia is voluminous, after several deep
incisions the whole of the mortified parts should be removed ; we may however
confine the incision to the intestinal loop and wait for the exfoliation of the
remaining tissues. Numerous cases attest that the system may then quite
easily effect a complete case. Traveling in Germany, J. L. Petit alighted one
day at a tavern, and was immediately struck with the odor of gangrene. He
was shown in the adjoining room a man laboring under the symptoms of hernia
with mortification. Thinking this man lost, he merely made some incisions
in the tumor, which immediately discharged an abundant quantity of matters.
On his return, twenty-eight days afterwards, lie learned, not without surprise,
that his patient was completely cured, and that without stercoral fistula.
Going, on another occasion, to La Ferte-sous-Jouarre, and losing his way in
the night, he stopped at a house in which he saw a light to inquire the road.
The woman of the house told him that her husband was at the tjoint of death
49
586 NEW ELEMENTS OF
and entreated him to enter. This was also a case of strangulated hernia,
which J. L. Petit contended himself with opening and cleansing, recommen-
ding them to use no other treatment, thinking that the patient could not
recover. A cure took place however, and the individual himself went sometime
after to inform the surgeon of it. But it cannot be denied, that it is better to
free the tumor with the scissors or bistoury of all its contents whidi are ■
evidently mortified. For the rest, there is no reason to act otherwise than if
the intestine alone were mortified, and the gangrene only known after opening
the sac. In this last case the gangrene may occupy only the most projecting
part of the strangulated loop, as it may have its seat even within the ring, and
on the points which immediately suffer the constriction. Several methods
have been advised in this case. One of the most ancient consists in opening
the intestine freely to give issue to the contained matters, and trusting for the
rest to the resources of nature. By acting in this way two things are to be
apprehended; first, that the stricture may be such as to render difficult the
passage of the substances which should pass through the alimentary canal ;
and secondly, the almost necessary estalDlishment of a preternatural anus.
To these apprehensions some reply that the ring is always large enough to
permit the end of the intestine in its natural state to preserve within it its
permeability ; that the inferior portion of this canal, receiving no more matters,
becomes obliterated ; that the portion corresponding with the stomach alone
continuing to receive the alimentary mass, must be suflGiciently free in the
herniary orifice, to fullfil without danger the functions of an abnormal anus.
On the other hand, experience shows that this practice has often been followed
by a radical and ready cure. The two cases just quoted are a proof of this,
and J. L. Petit relates others no less remarkable. Thus, being in Flanders,
this surgeon was called, on his way to Douay, to give his advice respecting
a tumor, which was strangulated and could not be reduced A charlatan,
whose advice the patient and his friends adopted, maintained that this tumor
was an abscess and ought to be opened. J. L. Petit declared that serious
accident might be the result, and that at least a stercoral fistula would follow.
On his return they assured him that the patient was perfectly cured. He
learned moreover that this man thus opened all strangulated hernias, and in
the environs of Douay and Cambray he had in this manner operated on a
great number of persons, which practice had given him a brilliant reputation
in the country. I saw last year a student of medicine who assured ine that
his father, a pi-ovincial surgeon, had been induced from experience to pursue
a similar method, and that ten or twelve times already he had used it with
success, whether the strangulated hernia was or was not attended with
gangrene. When it is remembered that preternatural ani of long standing
have in the end spontaneously disappeared, although the two ends of the
intestine had become fixed and stopped in the ring, and a considerable portion
had been removed, these results soon lose their marvellous aspect. In fact,
the intestine being opened and ceasing to be distended in hernia is a reason
also for the speedy disappearance of the strangulation. The elasticity of the
mesentery and the naturid movements of the cn-gans ccmtained in the abdomen,
must tend without interruption to draw towards their roots that which had
escaped in hernia. By degrees the two ends of intestine gain the posterior
face of the ring, and approach each other; their orifice? finally correspond ;
OPERATIVE SURGERY. 5ST
substances pass trom the superior to the inferior portion, instead of escaping
bj the wound, which also, by its retraction opposes a greater or less resistance.
All authors however do not view this in the same light. Scarpa directs, after
opening the intestine that the ring be incised more or less. Without this
precaution, says he, matters accumulated behind would have too much diffi-
culty in escaping, and might create a dangerous inflammation, supposing even
that they do not keep up the symptoms of strangulation. What danger after
all would there be in this practice ? The adhesions which he admits on the
limits of the gangrene would be full assurance of safety. Even when the
intestine would have to be incised from within outwards at the same time
as tiie sac or the fibrous ring that surrounds it, according to his views there
would be no reason to fear eiFusion into the peritoneum. Of late, M. Dupuy-
ti-eu, who strenuously opposes this doctrine, maintains that when there is
gangrene extending to the ring the edges of the herniary orifice are usually
Aortified, and that the intestine being opened the strangulation must soon
disappear of itself, and consequently render no kind of incision necessary.
He thinks besides that the adhesions pointed out by Scarpa are far from
being constant on the whole circumference of the intestine, and that they
would not oppose a sufficient barrier to the effusion of matters if the inci-
sion of the dio;estive tube was carried behind the rin*.
It is certainly incorrect to say that gangrene is never developed without
being preceded by adhesions between the neighboring serous surfaces. Several
times already has the opening of bodies who died from strangulated hernia,
convinced me that Scarpa has singularly exaggerated the importance of
this morbid condition, and that he was led into error as to the frequencv
and rapidity of its development ; that in fine these adhesions are sometimes
confined within such narrow limits that it would be difficult not to go beyond
tliem in giving freedom to the herniary circle through the intestine. On the
other hand it seems to me that mortification of the neck of the sac, and of the
edges of the ring, is much less common than M. Corbin and Caillard,
make M. Dupuytren to affirm, and that if we were to rely on it to terminate
the sti'angulation we would frequently have to repent our confidence. It does
not take place, for instance, when the mortification is in the free part of the
intestine. As the intestine is endowed with a vitality much more active, and
contains vessels in much greater number than the opening which compresses
it, it were to be presumed, if experience did not prove it, that in becoming
gangrenous in the ring it would not necessarily induce mortification of tHia
latter. I will add, that if we do not incise it, the intestine more or less
inflamed behind the destroyed part becomes generally the seat of considerable
swelling which invades its three tunics and principally its mucous coat, and
that this swelling arrested behind by the constricting circle is developed
almost entirely on the internal side, so as sometimes to produce a more or less
complete obliteration of the intestinal opening. I saw this in a woman treated
for hernia with gangrene at the hospital of Improvement, in 1824, and who
died the next day. It has also happened several times in other hospitals at
Paris within several years, if I may believe the report of several residents
sufficiently instructed to form a correct judgment on such questions. In short,
if after having opened the intestine the matters it contains, whether in tlie
liernia-or within the abdomen, freely escape by the opening, if the stricture
588 NEW ELEMENTS OF
of the ring is slight, incision is to be dispensed with. If on the contrary the
finger carried into the strangulated portion have difficulty in penetrating and
passing,prudence dictates in my opinion that this opening should be enlarged.
If the instrument can be easily passed between the viscus and the sac, without
exposing to destruction the adhesions which may exist behind, the incisions
may be performed as in the ordinary operation. If it be otherwise, the
bistoury is to be carried into the interior of the intestine, to cut from the
centre to the circumference in one or several directions the orifice through
which the matters are to pass. By reflecting on the natural disposition of the
parts, it will be seen moreover that these incisions expose less than is thought
to an effusion into the peritoneum. This effusion cannot in fact be feared,
unless the incision is carried beyond the posterior orifice of the ring, and
consequently much beyond the place occupied by the strangulation; the
stricture in these cases being almost constantly a little nearer the external
aponeurosis than i\\Q fascia propria or the interior peritoneum. This perhaps
may reconcile the ideas of M. Dupuytren with the practice of Scarpa. Yet
I cannot omit saying, that the danger of not incising in case of gangrene does
not at first appear very great. If after some hours the colic continues, tlie
symptoms of strangulation have not ceased, and in removing the dressing we
see that the matters escape with difficulty, we are then able to introduce
into the superior part of the intestine either a female catheter, a silver
canula, or still better a large tube of gumelastic, and thus remedy this diffi-
culty at once. If notwithstanding this attention the engorgement of the
tissues and the narrowness of the ring oppose the re-establishment o^ the
functions, it will be still time on the next day or the day following to dilate
by incision, as would have been done on the day of the operation, and perhaps
with less apprehension, since it is then almost impossible that solid adhesions
should not have been effected around the herniary opening.
§ 7. Enteroraphy.
We have as yet supposed the parts left in place, but a great number of
practitioners think it necessary, in order to be assured of the limits of the
gangrene, to draw through the ring a portion of the intestine which has not been
contained in it; to excise by cutting upon the living portion all that is
mortified; to reduce the sound parts so as to leave in the wound only the
opening or openings that have just been made, or to attempt on the spot their
immediate union by stretching together the two ends of intestine; hence have
arisen several important operations.
l^t. Littre for example tied the inferior end so as to produce its oblitera-
tion, and kept the superior end in the ring, establishing an artificial anus which
the patient was to carry during the remainder of his life. Louis, who was
not opposed to the practice of Littre, found however one difficulty, that of
distinguishing immediately the superior from the inferior portion of the ali-
mentary tube. To obviate this, he advised to give the patient a little syrup
of cichory, which being evacuated after some hours would indicate by its green
color in which direction was the stomach and in which the rectum. This
would be an ingenious mode without doubt, but it is rare that we are obliged
to have recourse to it. After tiie division of the intestine, its inferior end
OPERATIVE SURGERY. 589
rarely fails of collapsing and dwindling to the size of a large cord, while the
otlier preserves nearly its primitive dimensions, and besides does not cease to
give issue to fecal matters. The process of Littre, having for its end the
establishment of a disgusting infirmity ought to be rejected, and deserves not
the least attention at the present day.
2d. Lapeyronie has proposed another, at the same time more simple and
much more rational. The surgeon passes behind the division a double thread
through a fold of the mesentery, and after pushing the two ends of the in-
testine within the abnormal limits, uses this thread to prevent its being lost
completely by fastening them externally to any part of the dressings. An arti-
ficial anus is thus obtained it is true, but one that can be cured spontaneously
or by the assistance of art. Scarpa, who condemns this process of Lapeyronie,
directs after destroying the gangrenous parts to leave the two ends of the
organ in the wound. The adhesions which they have contracted, says he,
while the mortification was in progress, always suffice to prevent their too
rapid return and all danger of effusion into the peritoneum. According to
him the mesenteric thread would be injurious in more than one respect ; first,
in being an obstacle to the gradual retraction of the parts, and to the formation
of what the celebrated surgeon of Pavia calls the membranous funnel of the
artificial anus ; secondly because the thread, which will shortly cut through
the mesentery, may at the same time divide vessels from which hemorrhage
might be serious ; and in the last place, because, resting against the deeper
face of the intestines it is capable of causing ulceration and perforation, in the
same manner as a ligature cuts through an artery around which it has been
placed. But as the fears of Scarpa are not entertained by all surgeons, some
have put in practice the process of Lapeyronie even of late, and say they have
no reason to regi*et it. M. Hervez of Chegoin, among others, reported a case
to tlie academy of medicine, in 1829. It would be easy, besides, to leave this
thread in place for only one or two days if its presence proved really obnoxious.
Instead of forming a noose of it the two portions of which should be united or
twisted on each other, they may be kept apart by fastening them separately
without, and after a given time it would be very easy to withdraw this thread
by pulling one of its extremities before it could divide the mesentery or de-
stroy the continuity of the intestine. No doubt we may in strictness dispense
with the precaution of Lapeyronie when the excision has not been made in the
living part, or when it is very near the ring, and if during tlie operation we
have not thought proper to displace tlie strangulated intestinal circle ; but in
other cases it would be imprudent I think to leave hanging in the wound, as
Richter directs, a long portion of the divided organ, or to push it back into
tlie strangulating circle, as proposed by Desault, without taking the precaution
of fastening it by some means to the exterior.
Sd. Suture. — By following the course just marked out, the immediate result
will be a stercoral fistula, or a preternatural anus. The suture has been pro-
posed for the purpose of preventing this infirmity by immediately re-establish-
ing the continuity of the divided tube. This indication many authors have
endeavored to fulfill by various means, which having often sunk into neglect
has of late been again attracting some attention.
Upon a Foreign Body.— -To four gentlemen who united for the purpose of
relieving in common the poor patients of Paris, is attributed the first idea
590 NEW ELEMENTS OF
of bringing together the two ends of the intestine and sewing them. These
surgeons commenced, it is said, by procuring the trachea of an animal, and
introduced one of its extremities into the superior, and the other into the
inferior division of the interrupted canal, the two raw circles of which were
then approximated, and fastened and kept in contact by several stitches which
also passed through the trachea, and after some time were with it carried off
in the stools. G. de Salicet, who lived before Guy de Chauliac, does not
mention the trachea of the animal, but lie was acquainted with the process of
the four surgeons and formally condemns it. ''Do not listen," says he, " to those
who say that before sewing the gut, an ' elder pipe or some such thing should
be put in, and that upon this canula the wounded gut is to be sewed, for,' &c.
and further * it would be better a portion of the gut of some beast
but neither this nor any thing else- .' " For the rest, it is very certain
that the old surgeons had on this subject the idea which is at present enter-
tained. Guillaume only mentions it in incomplete divisions of the intestinal
circle, and expressly informs us that all others are necessarily fatal. Nothijig
shows that Guy entertained a different opinion, *' And if there is necessity
for sewing (the parts cantained in the abdomen), and that it be of benefit as at
the bottom of the stomach and large guts, let them be sewed with t!ie glover's
stitch. Some, as Garnier, Rogier, and Theodore, put into the gut a canula of
elder to prevent the feces from rotting the stitches. Others, as Guillaume
has related, place in it the portion of the gut of some beast, or a portion of the
trachea arteria as the four masters direct." Watson has since proposed a
, canula of isinglass. Some, with Scarpa, mention a cylinder of tallow. Saba-
tier, Ritch, Desault, and Chopart, direct a piece of a playing card smeared
with essence of turpentine or the oil of hypericum, or varnished in any other
manner. The process of the ancients had so little attracted attention,
that Duverger a surgeon of Maubeuge, who reproduced it at the beginning of
the last century, was thought to be its inventor. It does not appear after all
that it has been often tried, or that up to the present time there have been
more than two or three successful cases. If it is to be attempted, it would be
'in my opinion a matter of indifference whether to employ a very pliant animal
trachea, a cylinder of fish-glue, of card or paper, or a canula of gumelastic.
Having coated with varnish this species of tunnel or tube, which must ol'
necessity be somewhat smaller than the intestine, three or four loops of thread or
Ri'k are to be passed through the middle several lines distant from each other,
each carrying a needle at its extremity to make so many stitches. Its intro-
duction into the superior division of the alimentary tube will be attended but
with very trifling difficulty ; but for its admission into the lower portion, that
part should be held by two pairs of forceps, keeping its sides apart and thus
enlarging the opening. This being done, the ends of each thread ought to be
passed successively from within outwards, at two or three lines from the edge,
through the corresponding end of intestine. After they have been tied and cut
very near the knot, the whole is replaced in the abdomen ; a gentle purgative is
then given, and the patient treated as after the ordinary operation for strangu-
lated hernia. While the union is taking place, the threads are cutting through the
tissues, and when this is accomplished the foreign body being set free descends
with the intestinal matters and is expelled. Instead of four threads, Durverger
recpmaiends but two, one in front, the other behind. Those of Ritch, depend-
OPERATIVE SURGERY. 591
ing on the same cord, had the inconvenience of forming a kind of transverse
bridge in the interior of the card. Desault had no other motive than to remove
this peculiarity, in proposing the modification attributed to him, which is not
of sufficient importance to be given here in detail. This suture is in the first
place difficult to perform; and besides, it is to be feared that in the space
between the stitches union may not take place, and that becoming free the
threads may leave ulcerations, and allow fluids to be effused. In fine, its
dangers are so formidable, that in the absence of conclusive experiments and
numerous facts which science does not yet possess, despair of every other
means should alone induce us to determine upon its employment.
4th. Suture with Invagination. — Randhor, a surgeon of the duke of Bruns-
wick, having to treat a soldier in whom the continuity of the intestinal tube
had just been destroyed, concluded to introduce the superior into the inferior
portion, and fix it in this position by two stitches, reduce it, and leave it then
in the abdomen. His patient was completely cured. He died several years
after of another affection, and Randhor was enabled to examine the state of
the parts. He removed the portion formerly divided and sent it to Moebius,
who had occasion to show it to Heister, who immediately began to try the
same operation on dogs but without success. Extolled by some, rejected as
impossible or dangerous by others, admitted by Louis to be very ingenious,
and tried a number of times since it became known, the method of Randhor
seems to have succeeded but in a very small number of cases. M. Boyer
performed it once ; his patient died. In another case he could not finish it.
I have seen it tried by M.Richerand at the hospital St. Louis on a patient
who also died the next day.- M. Lavielle of Membaste, MM. Chemery Have,
Schmidt, and some others, have however each reported a case of success in
support of the Ranhorian operation.
The first difficulty is to overcome the contraction of the inferior division of
the intestine. One of the best means for this purpose, is to seize by their four
extremities at once the two principal diameters with as many forceps or
hooks. To prevent the superior division from filling or swelling an assistant
has to take hold of four or five inches of it and keep it sufficiently compressed,
while the surgeon endeavors to fix it in the orifice of the rectal portion.
But there is another obstacle, which M. Richerand I believe was the first
clearly and positively to point out. The researches of Bicbat on the different
tissues, prove in fact that mucous membranes will contract no mutual adhe-
sions ; and that adhesive inflammation in general only takes place between
cellular surfaces. But in the invagination after the manner of Randhor, it is
the peritoneal coat of the superior intestinal portion which is in contact with
the mucous membrane of the other. If the law established by Bichat is
correct, and if the remark of M. Richerand is well founded, adhesion of the
two ends of the intestine must be impossible by the method. Thus was it
nearly renounced, when M.Raybard advocated it anew, and endeavored to
show that it ought to be preferred to that which has recently been brought
forward to supply its place.
Process of M. Raybard. — In support of his assertions this surgeon publishes
a certiiin number of experiments upon living animals, and observations in
pathological anatomy gathered from man. Like Randhor, M. Raybard directs
the mesentery first to be incised parallel with the concavity of. -the intestine.
592 ' NEW ELEMENTS OF '
to the extent of several lines. He then passes a thread a little above the.
wound, so that one of its ends remains within the canal while the other
hangs without. According to him, it is sufficient to have two loops thus
placed, one upon each extremity of the antero -posterior diameter of the altered
canal. With a needle, the internal extremity of each is passed from within
outwards through Uie inferior division of the organ, to invaginate methodically
the two parts, and terminate by tying each stitch into a knot. M.Raybard
contends that his process is at once the most certain and easy, and much less
dangerous than that proposed by M. Jobert; I have not learned that he has
made any application of it to the human subject.
Suture with Contact of Serous Surfaces. — Experiments, already of ancient
date, may be brought to the support of M. Richerand's ideas. Messrs. Schmidt,
Thompson, and Travers have noticed this singular phenomenon, viz. that if a
thread is tied round a small perforation of the intestine, this thread soon
buries itself as in a depression, so as to approach gradually the interior of the
canal and there become entirely free, at the same time that the membrane^
or the serous surface approximates behind, and blends with a plastic layer, so as.
to prevent the opening which would otherwise be the consequence. Besides,
Mr. Travers has seen that if the whole calibre of the alimentary canal is .
strangulated, the peritoneum of the superior portion adheres so rapidly to
tliat of the inferior part, that the septum formed by this strangulation soon
becomes gangrenous, is detached, and carried in the direction of the rectum, so
that at length the tube is completely re-established. In France the labors of
M. Dupuytren on preternatural anus give the same fact, and show with what
facility and promptitude two points of the externalface of the intestine unite,
when kept in contact.
Process of M. Jobert. — From these various elements, M. Jobert has derived
a method which seems at first to promise real advantage. This surgeon
begins by turning inwards the orifice of the inferior intestinal division, he
then performs the suture like Randhor, and in this manner conti'ives that the
two ends of the organ shall be in contact by their serous surfaces. Two
threads are sufficient, he does not tic them, but keeps them without so as to
remove them after several days by drawing on their extremities. Experiments
made upon cats and dogs have, it is said, perfectly succeeded in his hands^
He has shown several to the committee of the academy of medicine, who have
seen the digestive tube fully cicatrized, presenting a solid ring, projecting
internally, and very complete at the place which had been occupied by the
wound. But this kind of invagination does not seem to present less serious
difficulties than that of Randhor, and at first view oiFers only the advantage
of plating in contact two portions of peritoneum, instead of applying tlie
peritoneum against a mucous membrane as in the ancient process. There
are wanting examples of this mode of proceeding on the human subject.
Process of M. Denans. — A surgeon of Marseilles, M. Denans, proposed
about the same period with M. Jobert another sort of invagination. Three
small hollow cylinders of metal are necessary for it. He places one in each
end of the intestine, the wound of which he inverts or invaginates on the in-
ternal face of this species of rings ; the third, a little smaller than the other
two, is to be passed within the upper one and then within the inferior, so as to
form a kind of staff or axis for the support of both. A thread embraces an4
OPERATIVE SURGERY 593
fixes all three upon two different joints of the intestinal circle. The ends of
the suture are cut very near the peritoneum, and tlie whole is replaced and
left in the abdomen. Union of the parts soon takes place. All tliat is
pressed between the three cylinders soon becomes gangrenous, is detached,
and these foreign bodies descend and are discharged by stool. At the last
meeting for admission M. Guersent, Jr. justified all the assertions of M. De-
nans by showing to tlie jury a portion of intestine perfectly cicatrized, the
two ends ot which had been coaptated by the process of the cylinders.
Process of M. Lembert. — M. Lembert, a former student in the hospitals of
Paris, proposed, in 1825, another method of bringing the serous surfaces
together. With an ordinary needle he passed as many threads as he wished
to make stitches through the parietes of the superior portion first, and then
through those of the inferior end of the intestine. The point of his needle is
carried two or three lines from the wound on the external surface of the
organ ; he makes it penetrate as far as the mucous membrane, passing be-
tween the tissues, brings it out at about two lines from its insertion, and thus
fixes his thread ; with the same precautions he directs the needle on the
external face and in the substance of the rectal end of the intestine, applying
successively and in the same manner all the threads he deems proper, and has
then only to tie them to complete the suture. By drawing upon these threads
the lips of the wound are forced to be inverted on their internal surface, for-
ming a valve or border projecting into the interior of the canal, producing at
the same time the immediate contact of the external surface of the ends of in-
testine whose continuity is to be re-established. These three processes tend
to the same end, the union of two serous surfaces. That of M. Denans seems
to offer more certainty and less danger than the two others, inasmuch as
nothing can derange it. However, who would be so bold as thus to leave the
intestine in the abdomen ? Who can insure that these inflexible cylinders
will not perforate the organ if tliey should take a wrong position in the inte-
rior of the abdomen ? In operating like M. Jobert there is danger of the
threads relaxing, and some points of the intestinal periphery may remain
disunited and permit effusion. The modification ofM. Lembert is apparently
much more simple and easy, it requires no previous inversion nor invagina-
tion, but it seems to be more likely than the preceding to leave some vacancy
between the stitches, through which substances of some fluidity may escape.
If I intended to employ it I would prefer using the overcast stitch ; that is, I
would pass the needle obliquely from above downwards, from the superior
end over the external face of the inferior, so as to reascend to the first a line
or two from the point of departure, returning upon the second, and then again
to the first, and so on until I had gone over the whole circumference of the in-
testine. To finish I should only have to draw in different directions the two
ends of the thread, of which one would be the beginning and the other the ter-
mination.of the suture. If simple pulling will not force the lips of the wound to
become inverted, and the peritoneal coats to come into mutual contact, the
beak of a sound will complete the suture with great facility. A double knot
will then finish the operation. The extremities of the thread or one of them
will be sufficient to retain the organ behind the ring, if we do not wish to
leave it at large in the abdomen, in which case a knot is not indispensable.
But after aJl, does pi-udence permit us to have recourse to such means, means
75
594 NEW ELEMENTS Ot
which will necessarily produce death if they should fail of their intended effect B*
Is it right thus to risk human life, when by establishing an artificial anu»--
we are almost sure of an eventual cure ? I have practised upon dogs the pro-
cess of M. Jobert and that of M. Lembert modified as I have just shown.
Whether it was that I did not take all proper precautions, or that I had not>
the skill necessary for tlie attempt, I must confess, that in two cases out oP
six fecal matters were effused into the abdomen, and the death of the animals
was the consequence. I will add, that of the other four only two were per-
fectly cured, while the third and fourth retained a small orifice tlirough which
escaped mucosities, and which were not surrounded with adhesions or false
membranes and gave no favorable assurances for the future. I also wished
to renew the experiments of Mr. Travers, and the truth is, that in the two
dogs, all that I tried, the strangulated intestine broke, and I found it wholly,
divided after the death of the animals, which took place on the following dayi^
B. Ulceration. — What I have as yet said is only applicable to wounds
which include the whole of the intestinal circumference, either with or without
loss of substance, whetlier dependant on gangrene or a wound on some point
of the abdominal cavity. If the mortification is confined to the peritoneal
coat, or does not extend to tlie mucous membrane, we may, as Desault
recommends, restore their parts to the place, and trust entirely to the resources
of nature. Adhesive inflammation will be developed around the altered layer,
and soon produce exfoliation of the dead lamellae, and will not permit the*
intestine to be perforated. But one of two things is true : either tlie gangrene
is evident, and in this case not having any certainty whether it extends or
does not extend through the substance of the organic parietes, the surgeon
cannot think of reduction; or, its existence may be doubtful, and then
prudence directs that the intestine be returned into the abdomen. If it
occupies but a small space, the part may be cut out, including some of the
living portion, and so as to form an elliptical wound, longitudinally or
transversely as it may be easiest to make it in one or the other of these
directions. On the contrary, if it occupies a great part of the circumfe-
rence of the intestine, and that for more than half an inch, it would be
better to remove a complete segment of this cylinder, and to try one of the
methods pointed out above. The gangrenous portions being removed, the
solution of continuity is reduced to the slate of a simple wound, and is to be
treated as such. Modern experience has proved that the perforation of an
intestine by a penetrating or cutting instrument may be left without danger
in the abdomen when it is less than two or three lines in diameter. The
muscular fibres soon contract its circumference, so as to force the mucous
membrane to become engaged in and close it. A larger incision, one of three
or four lines for instance, does not more constantly cause extravasation ; its
edges adhere sometimes to the corresponding surface of another intestinal
circumvolution, or it comes in contact with a fold of epiploon, which often
engages in it and closes it like a stopper. It would be imprudent, however,
when 8uch lesions are visible to leave them to the care of nature. If it is
true that the greater number of them are healed without giving rise to unplea-
sant s}Tiiptom8, it is also very probable that some would be followed by fatal
effusion. In hernids these wounds present under two distinct forms, first, in
the state of a simple division when they are produced by the cutting instru-
OPj^RATIVE SURGERY. 395
ment used by the operator ; secondly, under the aspect of ulcer or solution,
with loss of substance if stricture in the ring has been the cause. In this
last case there is scarcely any hope of seeing them closed without assistance,
and if they are to be treated by tlie suture it is proper first to smooth their
edges. We have here to choose among the glover's suture, the suture of Le
Dran, and the suture a points passes. The glover's suture has the advantage
of being quickly and easily performed, and of exactly closing the wound,
but it is very difficult to witlidraw the thread when we think union is effected.
Besides being less quickly performed, the suture a anse, or of Le Dran, has
the inconvenience of puckering and contracting the intestine in consequence
of the size of the wound ; but the threads being passed but once through the
tissues are. easily drawn and removed through the opening in the abdominal
parietes. The suture a points passes offers nearly the same advantages as the
glover's suture, and if modified as directed by Bichat its removal is less liable
to produce rupture of the adhesions and growing cicatrix than the simple
overcast stitch. The spiroid suture, combined with the principles of M.
Lembert, seems no less entitled to respect. Whether the wound be longitu-
dinal or transverse the operation is always to be performed after tlie same
rules.
When tlie coaptation is effected, we may act in two different ways ; first we
may tie the suture and cut it close to the intestine, then reduce this, and leave
it free in the abdominal cavity ; or secondly, we may keep the tliread and
fasten it externally in the dressing, to prevent the wounded organ from
escaping to any distance, and to force it to contract adhesions behind the ring.
If it were true, as it is asserted, that ligatures fixed in the substance of the
coats of the intestine always fall into the interior of the canal, the first method
should evidently be preferred, since the other would not fail to obstruct in
some degree the passage of intestinal matters ; but most surgeons of the
present day have not as yet adopted this plan. The two cases of M.Cloguet
and M. Liegard, who followed the process of M. Lembert, are in fact the
only ones as yet to be brought in its support ; and quite recently too, M.
Hervez of Chegoin preferred passing a thread into the mesentery to retain
the wounded organ to attempting the suture, although the wound was not more
than. two lines in diameter. M. Raybard maintains that the principal end of
enteroraphy is to fix the two lips of the solution separately behind the open-
ing in the abdominal parietes, so that after they have been united with the
peritoneum the threads may be drawn, and the division of the abdomen and
that of the intestine healed at the same time. If it be a long wound this
practitioner conducts the operation in the following manner. A flat piece of
white wood, small, thin, and oiled, from twelve to fifteen lines long, and from
four to six broad, is carried into the intestine. A loop of thread attached to
the middle of this slip of wood, armed at each end with a needle, is then
passed from one side to the other, from the interior to the exterior, through
the whole substance of the abdominal parietes, so that the small foreign lamella
presses at once the two lips of the intestine against the two sides of the
abdominal wound, which at the same time it keeps hermetically closed.
When the adhesion of these various parts seems sufficiently solid, M.
Raybard withdraws his thread, the slip of wood comes away with the stools,
when the cicatrization of the wound in the abdomen only remains to be at-
59o NEW ELEMENTS OF
tended to if not already healed. If this process is blamed for intetitidnally
producing adhesions which will necessarily prevent the intestine from'resum-
ing its primitive mobility, it is but just to acknowledge that in other sutures
the same thing almost as certainly takes place, if not as completely, whenever
the extremities of the thread are kept without. It is even true that it is not
more thoroughly avoided by cutting the threads close to the intestine and
leaving the organ behind the wound. Adhesive inflammation, which is indis-
pensable to cieatrization, seldom fails of uniting the circumference of the vis-
ceral wound to the tissues which are in more or less immediate contact with
it. Another objection better founded is the use of the slip of wood, which
seems hardly applicable to any other than longitudinal divisions the conse-
quences of penetrating wounds of the abdomen, and not to cases where the
parts have escaped through a herniary opening. For the rest we niay have
to fear lest the extremities or edges of this foreign body perforate the parietes
of the wounded intestine by ulceration or gangrene. It must be admitted,
however, that in wounds of the convexity of an intestinal loop, this process
seems worthy of trial; the better, as it permits at once the immediate union
of the abdominal wound by the twisted or quilled suture, or the siiture a points
passes ; if not by the same thread which passes through the intestine as di-
rected by M. Raybard. To resume ; therefore, whether the intestine be held
or left at large it does not cicatrize without uniting in some measure with the
surrounding parts, so that on this point eveiy one may be free to act according
to his own ideas. Therefore I cannot seriously blame M, Guillaume for having
sewed the external wound with the glover's suture, for a patient whom he
treated for a division of the intestine. To conclude, if the parietes of the
organic cylinder were only divided or perforated to the extent of one or two
l;nes, it would be better to take hold of the two lips at once with a forceps and
close it by passing round it a thread, as in tying the extremity of an artery.
Sir A, Cooper and another surgeon I think have each had a successful case
by this method in the London hospitals.
§ 8. Preternatural Anus.
The operations by which art sometimes remedies the preternatural anus
are rather few in number. For a long time none was eveYi attempted,
and it is only since the middle of the last century that operative surgery has
positively undertaken the relief of this disgusting affection.
A. Suture, — One of the first processes that presented itself to the mind,
waft the suture. It seemed that by approximating the lips of the wound or the
integuments previously pared, and keeping them in contact, we might succeed
in forcing the matters to resume their natural course and enter the inferior
portion of the intestine. Lecat is the first who expressed a desire to put this
method into execution. He had admitted into his hospital a woman affected
for several months with preternatural anus in 1739, and for the purpose just
pointed out; but various circumstances independent of his will caused his
project to fail. Lebrun was more fortunate; he put in practice the idea of
liccat. A crucial suture appeared to him sufficient in the patient he had to
treat. He uged only caustic for making rare the lips of the wound. For two
days every thing presaged success. There were no bad symptoms, and cica-
OFERATIVE SURGERY. 597
tiization was alreaiSy far advanced, when on the third day it became neces-
sary to remove the threads and give issue to the intestinal matters. Lebrun
intended to recommence the operation afterwards, but the patient would not
on any account consent. This attempt has been generally blamed, so that
few surgeons have been bold enough to renew it. It was however renewed
some years since by M. Judey for an accidental inguinal anus of four months'
standing, the consequence of gangrene. The success was complete accord-
ing to M. Richerand who communicated the fact to the academy of medicine.
M. Blandin seems to have been less fortunate. He once attempted to close a
preternatural anus by the suture, but the symptoms that soon manifested
themselves, obliged him to re-oj}en the wound. A modification of this process
could not fail of being, and in fact was proposed about twelve years since.
The integuments in general are so hardened and blended with the subjacent
layers around the w^ound that it would be extremely difficult to approximate
its lips or bring them in contact. M. Collier thought that a portion of skin
detached from the neighboring part, turned over and fixed by stitches or pins
in the anus according to the principles of rhinoplasm would obviate this in-
convenience. A patient thus treated by him was completely cured, and this
mode of operating has received the approbation of M. Dupuytren, in cases at
least where there remains only a stercoral fistula after the re-establishment of
the alvine evacuation by the natural anus. Perhaps there would be an advan
tage also in modifying tliis last idea by dissecting the skin which surrounds
the abnormal anus to the extent of an inch or two, preserving on its internal
face as much cellular tissue as possible, and then making raw the ulcerated
edges to give them a form more elongated and regular, and then fixing them
with one or more points of twisted suture. The approximation will then take
place without the least difficulty or dragging of the parts. A moderate com-
pression would be then indispensable as in the preceding process, in order to
keep the deeper surface of the dissected flaps in contact with the parts from
which they have been separated, and prevent tlie intestinal matters from ^
being effused betM^een them. On the whole, suture of the abnormal anus is
bad and should be proscribed. It is proper only in certain cases to complete
tlie cure which sometimes remains imperfect after other treatment, or when by
any means the course of the stools is re-established, and when for several
months the stercoral orifice has given issue only to mucosities, biliary matters,
or other intestinal fluids, and when in spite of every care and the best devised
dressings, this orifice still remains. The suture by tJie process of M. Collier,
or by dissection of the circumference of the wound may, I think, find in this
case its proper application, and conduce to success.
B. Compression. — Compression is a means which has more than once been
employed with advantage, and is still frequently used. It is besides, often
indispensable as a preparatory step or a supplementary one, to remove certain
complications which render other processes altogether impracticable. Thus
the intestine may' be invaginated through the preternatural anus, protrude
externally, and in the end form a tumor which has in some subjects been seen
to acquire a size of six inches, a foot, and even more in length, taking a
cylindrical form, from the extremity of which fecal matters are discharged.
It is evident that such an invagination constitutes a serious malady ; and as
many surgeons have remarked, its root is subject to strangulation like every
59S NEW ELEMENTS OF
other species of hernia. Patients have died in consequence of it, and I need
not say that when this strangulation exists, we ought if reduction is impossible
to lay open the ring and incise it from within outwards ; in a word, remove
the stricture as in ordinary hernia. Even in the absence of all stricture the
intestinal cylinder witli its mucous membrane turned outwards does not
remain long in this position without undergoing alterations. Thus it is to be
apprehended that tJie peritoneum of the invaginated portion will soon contract
intimate adhesions with that of the ensheathing portion, and the other tunics
thicken and become hard, so as to render the reduction difficult if not alto-
gether impossible. To remedy accidents of this description when not beyond
the resources of art, compression has been advised. Desault, Sabatier, and
Noel of Rheims, have vouched for its efficacy. Since then it has become in
some sort a vulgar remedy. If the tumor is long, it is enveloped with thin
compresses, after being cleansed ; then a bandage is applied rather narrow
than too wide, and is arranged in the same manner as a roller upon a limb.
At first the diminution of this mass being very rapid, the bandage ought to be
frequently reapplied ; afterwards it is to be renewed at longer intervals. If
the serous surfaces of the organ do not oppose an invincible obstacle, its
reduction will soon become practicable. For the rest, it is evident that after
this reduction the preternatural anus will nevertheless continue to exist, and
other means must be used to make it disappear. As the projection, the kind
of buttress or prominent margin which separates the superior intestinal portion
from the inferior, is the principal obstacle to the passage of substances from
the former into the latter, it was natural to expect that by pushing back this
projection the disease might be cured. Compression was therefore proposed.
It was in the school of Desault that it found most partizans and received
useful improvements. By means of- tents, introduced first into the inferior
end and then into the superior and fastened without by a thread passed around
the middle, Desault was confident of freeing a passage to the matters, which
would not be long in following. His tent being placed, he applied a pyramidal
tampon to support its convexity and push it as much as possible into the
abdomen. When these tents could be introduced of considerable size, and
the stools had returned almost to their natural freedom, he only compressed
the external opening to prevent all oozing by it. It cannot be denied that a
treatment so well contrived has more than. once been attended with success.
However, tiie presence of a tent filling both portions of the intestine, and of a
pyi-amld of charpie,or compresses hermetically closing the wound, is not borne
without inconvenience by every patient. Some suffer from colics, and pains
so acute as to oblige them to abandon it. Another means of obtaining the
same result has sometimes been employed at the Hotel Dieu. It is a kind
of crescent of ebony or ivory from six to eight lines long, with a handle from
five to six inches in length, and furnished with a sponge or compress. Carried
to the bottom of the accidental anus, it embraces in its concavity the intestinal
promi-ience, which is pushed back by pressing upon the handle wrapped with
linen, and which it is easy to fix by means of a truss or other appropriate
bandage.
C. Enierotomy or M, Dupuytren^s method, — Notwithstanding compression,
the most methodical and best applied, the preternatural anus sometimes resists
the eftbrts of the surgeon, and continues to the despair of the patient. The
OPERATIVE SURGEBY. 599
eflferts of Scarpa, in throwing light upon the mechanism of this affection, have
shown that what this author calls the promontory, results from the conjunction
of the two ends of the intestine which present behind the ring, in tlie manner
of a double barreled gun. This being the case, it was natural to endeavor
not only to push back this projection but even to destroy it. Schraakhalden
seems to have had the first notion of this, and published it in 1798, in his
inaugural dissertation. He directs a curved needle to be passed through the
base of this prominence, and a strong ligature to be introduced in order to cut
by degrees in the direction of its length upon tightening the thread, or acting
as in fistula ad amim by apolinosis. According to J. S. Dorsey, his father in
law. Dr. Physick, tried a similar operation in January 1809, and completely
succeeded.
The proposition of the Grerman surgeon had made no impression in his
country, and that of the American author would probably have passed un-
noticed, if about the same time, in 1813, M. Dupuytren had not undertaken
on his part to introduce it in France, and especially if he had not arrived at a
method much more certain and more efficacious. Like Dr. Physick, the sur-
geon of the Hotel Dieu confined himself in his first operations to the carrying
of a thread through the projection, so well described by Scarpa, in order to
cut it from behind forwards. The adhesions contracted by the peritoneal
Surfaces around the union were sufficient to prevent all effusion into the
abdomen. The matters being no longer gathered about the ring, and finding a
passage through the inferior portion, necessarily took the course towards the
rettum. Although several attempts confirmed these anticipations, M. Dupuy-
tren soon discovered that the needle might be carried beyond the protecting
adhesions, and perforate a point of the alimentary tube which communicated
with the cavity of the peritoneum. Alarmed at this danger he thought of
enterotomy, and for fifteen years followed it with almost constant success.
His pinciers, the internal face of the beak of which is undulated so as to em-
brace the parts more exactly and prevent their sliding upon each other, is
jointed like a forceps, and closed by a screw througli their handles. One of
the branches of this instrument is to be carried into each portion of intestine,
so as deeply to embrace the projection for the extent of an inch or an inch
and a half. Pressure must then be sufficient to determine mortification of
the parts and so stop the circulation immediately. The mechanism of this
process is easily conceived. The peritoneum is necessarily brought in con-
tact with itself on the circumference of the enterotome. Eliminatory inflam-
rnation is gradually developed and transmitted to some lines beyond. Solid
adhesions are the inevitable result, and no perforation on the side of the peri-
toneum is then to be dreaded. In proportion as the eschar is detached the
instrument becomes more and more movable, and comes away when it is
entirely insulated. If the compression was not sufficiently powerful at first,
the blood might still be introduced between tJie blades of the forceps, in
■which case gangrene would not take place. The external peritoneum might
hot have inflamed to the point necessary to produce proper adhesions. A
perforation towards the cavity of the abdomen would be to be apprehended,
and the detachment of the morbid septum not effected. The pain besides
"would be morQ violent, and the cure slower even if it ever took place. This
method, employed more tlian twenty times by M. Dupuytren, since by
600 NEW ELEMENTS OF
M. Hej of BonneTal, Lallemand, Delpech, and other practitionei's, has
not as jet occasioned any serious symptoms except on 4;hree or four patients.
When the perforation has been eftected the matters are drawn to the inferior
intestine, and the stools become regular. Every day less is passed by the
wound, which rapidly contracts and is soon reduced to a simple fistula, if not
wholly cicatrized. Fever rarely supervenes; colics or symptoms of slight
inflammation of the intestine or peritoneum are the only unpleasant symptoms
that have been observed, and most frequently the patient scarcely suflTers
from the operation.
* Some persons have nevertheless attempted further improvement by modi-
fying the enterotome forceps. Thus M. Liotard in his thesis proposed an
instrument, a kind of punch -plyers, which is to cut out a circular portion of
the morbid septum, without touching its free edge, and so that there will
result an opening in some measure similar to that of a natural intestine. This
process^ which is unapplied as yet, would have the disadvant^e of not suiting
every case, of exposing to be cut some sound portions of a free loop of intes-
tine, whicn may have placed itself behind or between the two branches of that
of which the septum is to be perforated, and finally of beinjj; too difficult of
execution, for the.plates of M. Scolard are too large to be easily introduced
through a preternatural anus, and through the ends of intestine themselves,
which in this case are usually very much contracted. M. Delpech has made
use of an instrument which acts pretty nearly by the same mechanism as that
of M. Liotard. It is a long forceps terminating in two knobs, a little elon-
gated, similar to the shells of a walnut, the circumference slightly concave in
the direction of their length. These are separately introduced. As they at
first compress only at their beak, they divide the septum but by degrees and
from behind forwards, while with the enterotome of M. Dupuytren, com-
pression being generally stronger the nearer the heel of the instrument, it is
from before backwards that gangrene is produced. M. Delpech has well per-
ceived that his forceps, useful perhaps in particular cases, is incapable of gen-
erally supplying the place of that of M. Dupuytren. It may offer some
advantages I suppose when the partition is extremely long and deeply seated,
or when to reach it we are obliged to pass through an irregular passage
more or less sinuous ; but these are circumstances which always escape from
tile rules of a general description, and must be left to the skill of those who
meet with them.
In this method, as in every other, two things are to be separately considereid,
the end and the means. It appears to me that there can be no variety of
sentiment at present except upon the last, and there is no reason why attempts
should not be made to modify them further. »Since, by depressing the pro-
jection in the preternatural anus a passage is opened, why not make this
depression by a canula, which will at the same time allow of cicatrization of
the exterior division? This advice was given by M. Colombe in 1827;
and M. Forget informs me that since 1824 he has advanced a similar sugges-
tion. M. Colombe directs a large canula of gumelastic two or three inches
long to be placed in the two ends of tKe intestine, a canula slightly curved
which will rest by its concavity on the free edge of the septum, and will carry
on the middle of its convex side a thread intended to hold it until the wound
b almost entirely closed, or the course of matters so completely re-established
as to leave no longer any fear of their escape externally.
OPERATIVE SURGERY. 6©1
At tjie first glance, this method appears to deserve consideration, and seems
specially suitable for cases in which the re-entering angle formed by the me-
senteric wall of the intestinal loop is very open, or the projection is not very
great, particularly for those in which the intestine has not been destroyed in
the whole of its circumference ; but it is to be feared that in others it will be
insufficient, and must be counted inferior at least to that oi M. Dupuytren. I
will add, that to have great chance of success it is necessary to use a very large
canula, the introduction of which will at first be attended with considerable
- difficulty. I practised it in August 1831, at La Pitie, and the patient died
three days after of intense peritonitis. The intestine was perforated behind
and the canula engaged in the orifice. Whether this be referred to cause and
eft'ect or to simple coincidence, such a result does not argue much in favor of
the method.
Operative Process. — When the surgeon has decided upon attempting the
cure of artificial anus, he must first think of surmounting the obstacles which
in some cases oppose the introduction of tlie enterotome. If the integuments
have not been widely opened, or if from any cause sinuous passages, or ster-
coral fistulas are observed in its vicinity ; if a tumor, sinuses, or erysipelatous
inflammation exist in front of the canal which it is proposed to pass through,
doubtless the first step should be to remove these various obstacles, either by
incisions and even proper excisions, or by general or local bleedings, emollient
Or laxative topical applications, baths, lotions, &c. In a patient, in whom the
strangulated hernia had never been operated upon, I saw five or six openings
and a tumor as large as the fist form in front of the ring, caused by thickening
and chronic phlegmasia of the skin, the cellular or adipose tissue, and the
different lamellse contained in the inguinal canal. I was therefore obliged to
circumscribe this mass by two crescentic incisions, and in removing it, to
penetrate as far as the root of the spermatic cord in order to display the intes-
tinal orifice. In such a case, it should be recollected that the operation ought
to be performed at two difi*erent periods; that is, before proceeding to use the
enterotome we should wait till the preparatory wound has healed. At other
times we are obliged to dilate for a week or two the preternatural anus itself.
In some cases the cutaneous orifice is so far from the intestine that there is
great difficulty in penetrating the latter. The perforated portion may besides
have remained crooked, and be bent either in the interior of the canal itself or
behind the ring, forming folds which may have contracted adhesions among
themselves, and may thus give rise to difficulties which it is necessary to over-
come before proceeding further. The inferior end, which is always strongly
contracted, may again be placed above the upper, around which it may be
twined, of which an interesting case may be seen in the memoir of Mr. Del-
pech. Although very rare, the obliteration of this part of the alimentary tube,
however old the disease may be, is yet possible; a fact observed at the Val-
de-Grace, on an old man, aftected for forty years with accidental inguinal anus,
demonstrates it beyond dispute ; so that it is well to remember it before car-
rying the forceps upon the wall of partition which it is intended to destroy.
If then the wound is situated at any considerable depth, and there is any doubt
-of the nature of the relations existing between orifices of the abnormal anus,
we should endeavor gradually to dilate the passage which leads into the su-
perior intestine, and do the same with the inferior by the introduction of long
76
602 NEW ELEMENTS OF
tents, bougies, sounds, gumelastic canulas or pieces of prepared sponge, and
never have recourse to tlie enterotome, before being able with the finger to
ascertain the position of the parts and the relation of the septum with each end
of the intestinal tube.
When we have arrived at this point the operation itself may be performed.
The patient is placed as for celotomy. The fore finger of the left hand serves
as a guide to one of the branches of the forceps, which it conducts under the
inferior face of the projection which is to be destroyed. An assistant is to
keep this in place while the operator in the same manner introduces the other
into the upper end of the affected tube. He then takes hold of both, turns
them on their axis so as to be able to close them, carries his finger again nearly
to their extremity to ascertain how far they embrace the promontory, and to
push them without fear as far as he wishes the consequent mortification to ex-
tend. The screw, or any other means intended to bring them together, is then
applied upon the extremity of their handle, and compression cairied to a
degree, as has been already said, proper to suspend circulation and vitality in
the septum which they grasp. It only remains to surround them with charpie
and compresses and fix the whole with a bandage, and the operation is finished.
The charpie and other dressings are to be renewed as often as the flow of mat-
ters is necessary, taking every precaution however not to derange the position
of the forceps. Any symptoms that may be developed are to be met by the
requisite treatment. As soon as any gurgling is heard, and tlie least tenesmus
manifested, injections more or less stimulating are positively indicated,
especially when the instrument begins to get loose, and if the separation of the
eschar seems already to have taken place. The remaining treatment has nothing
peculiar. The patient should preserve the horizontal position, from time to
time take a laxative, have frequent recourse to clysters, and take all kinds of
nourishment. By this means the external wound is often entirely closed,
although in general some weeks, and even in some cases it appears months are
necessary to accomplish it. There are persons also in whom this opening
reduced to a simple fistula resists every treatment, and obliges the surgeon to
employ only palliatives. To this obstinate continuance, which there, is nothing
apparently to keep up, we have opposed, says M. Dupuytren, without any
great result, powdered colophony introduced into the fistula, cauterization of
iti-edges with nitrate of silver, their approximation by adhesive strips, excision
of their edges formed of the skin and mucous membrane, in fine their union
by the twisted suture ; we have even conceived the idea, in order to keep them
in contact, of approximating them by means of two oblong pads fixed to a
girdle, and connected together by two screws. This apparatus had no better
success than the others. It is therefore, an infirmity which requires new-
researches, new modes of treatment, and against which we are obliged to con-
fine ourselves to the use of means to preserve cleanliness. As it only occasions
a slight oozing, it is enough to keep a little soft charpie upon the sore, and to
renew it several times a day, in order that the mucosites and other intestinal
fluids which it imbibes, may not have time to become decomposed or fetid by
their accumulation. In this case it is proper in my opinion to try tlie pro-
cesses borrowed from rhinoplasmus, after the manner of Dr. Jameson or M.
Collier, unless we choose first to make trial of dissection and elongation of;
the edges-of the abnormal anus. Tn case of a preternatural anue, the cure of !
/ OPERATIVE SURGERY. 603
which cannot or should not be attempted, the best means to be employed is
the box invented by Juville. Any other vessel constructed on the same prin-
ciples will serve the same turn ; and may be found in plenty with truss-makers
or manufacturers of gumelastic surgical instruments.
B. PARTICULAR HERNIAS.
ARTICLE I.
Inguinal Hernia.
§ 1. Anatomical remarks.
The points of the abdominal wall that give passage to the viscera in cases
of inguinal hernia, are bounded below by the ligament of Fallopius and the
OS pubis, above by the inferior edge of the transverse muscle, and internally
by the tendon of the rectus. Poupart's ligament extending from the anterior
superior spine of the ileum to the spine of the pubis, represents a cord to
which we may give three edges ; first, inferior, which is continuous with the
aponeurosis of the thigh, and which we shall have occasion to study hereafter ;
the second, superior and subtegumentary, which receives the aponeurotic
fibres of the external oblique muscle ; the third, posterior or peritoneal, from
which arises the fascia trayisversalis. The cutaneous margin, which is so
completely continuous with the external aponeurosis of the abdomen that
many authors have regarded it as its termination, requires to be distinguished
from it. This aponeurosis, in fact, is constituted of solid fibres united in lit-
tle bands, which sticking upon Poupart's ligament form with it an angle the
more acute the nearer they approach the symphisis. The separation of its
fibres into two divisions in arriving at the body of the pubis, forms the exter-
nal opening of the passage througli which the spermatic cord passes, and
this opening is not owing to the division of the internal extremity of the liga-
ment of Fallopius. These fibres are besides supported by a kind of web of
condensed cellular tissue which is found in the composition of all aponeurosis,
and crossed at right angles by other fibres much more sparse (and sometimes
even entirely wanting, especially in early life) ; which when quite numerous
give it the appearance of a distinct tissue. The posterior edge of the liga-
ment of Fallopius is continuous with a lamina upon which there has been
much discussion of late years, and which received only cursory notice until
it was described by Sir A. Cooper. From it the fascia transversalis, ascen-
dens, reflexa, &c., ascend behind the posterior face of the internal oblique
muscle, arrive on the corresponding face of the transversalis, and extend
transversely from the spine of the ileum to the rectus abdominis. Its fibres
are parallel to each other, and are directed a little towards the median line in
its external half. It is very thin, and most frequently reduced to the form of
a cellular lamella in the latter direction, but is more solid and incontestibly
fibrous in its internal moiety. Its aspect varies singularly according to the
subject, age, and sex. In infancy and in the female it can scarcely be distin-
guished from the cellular tissue which usually covers its two faces, while in
the adult man, and especially in a lean subject, it forms an aponeurosis, the
existence of which cannot possibly be called in question. Its presence in
604 NEW ELEMENTS OF
this place is but the repetition of the aponeurosis of the external oblique mus-
cle reduced to its elementary condition. Holding in some sort a middle
place between the cellular tissue and fibrous layers proper, the descriptive
details of it which have been given are the less justified, as every large mus-
cle is covered with a lamella nearly similar, either externally or internally,
when they have not a true albugineous covering. It is further necessary not
to confound it with the peritoneal cellular tissue, from which it is as distinct
as the aponeurosis of the external oblique is from the fascia superjicialis, with
which the fascia transversalis has been incorrectly compared. The opening
which it presents a little without the middle of its width, gives passage to the
spermatic cord, rests on Poupart's ligament, and sometimes extends so high
up as to form an actual division between its two halves. In some subjects
the internal moiety of this fascia is really all that can keep the name of apo-
neurosis, the other portion is so thin and analogous to cellular tissue.
Between these two fibrous layers are found the inferior fibres of the trans-
versalis muscle, and particularly those of the internal oblique, some bundles
of which arise from the gutter between the two edges of the ligament of
Fallopius and form the creraaster muscle. Of late years surgeons have
agreed that the opening which gives passage to a bubonocele is not a simple
ring as formerly described, but an actual canal, having an anterior and a pos-
terior orifice and an intermediary space. This disposition, of which Riolan
the younger had an imperfect ideay.ashad also Gimbernat, who pointed it out
positively in 1787, and afterwards in 1793, seems nevertheless not to have
been known toRichter, nor the surgeons who wrote before Scarpa, A. Cooper,
Hesselbach, &c. At present, as the fact may be confirmed by every one on
the dead subject, its existence is not thought of being called in question,
though there are some practitioners who are not willing to give it the name of
canal.
Supposing the spermatic cord removed, we may accord to the inguinal
canal, first, an anterior or external wall formed by tlie aponeurosis of the
external oblique, some fibres of the internal oblique and loose lamella of cel-
lular tissue; secondly, a posterior wall formed by the internal portion of the
fascia transversalis, thirdly, a superior side belonging to the edge of the
transversalis muscle or to the union of the two aponeurosis just mentioned ;
fourthly, an inferior wall, which is only the internal third of the groove formed
by the separation of the external aponeurosis and the fascia transversalis.
Its direction is oblique from behind forwards, from without inwards, and a
little from above downwards. One of its two openings corresponds to the
cavity of the abdomen, the other to the integuments. The first ordinarily
presents the form of an ovel, its base resting upon the ligament of Fallopius,
while its apex is prolonged towards the transversalis muscle; its internal
margin, the firmest and most prominent, has received from some authors the
name of falciform edge ; the external, a little more depressed and less appar-
ent, seems in the greater number of cases to be blended with the correspond-
ing wall of the canal, in which it is insensibly lost. The second, or the ring
of the external oblique, is triangular and formed below by the edge of the
pubis, within and above by one of the strips of abdominal aponeurosis, and
without by the termination of Poupart's ligament as well as another bundle
of the aponeurosis of the external oblique. Surgeons usually give the name
OPERATIVE SURGERY. 605r
of pillars to its two principal edges, and make them rise from the bifurcation
of Poupart's ligament, which as we have seen is a material error. The
internal pillar goes to be blended or crossed with its fellow before the sym-
phisis, and belongs entirely to the aponeurosis, while the external is alone
formed by tlie ilio-pubic ligament; besides it is completed superiorly by the
termination of another band of the external fascia. The superior angle of
the ring extends sometimes very high and very far outwards, while on other
cases it is much depressed and as it were destroyed by the transverse fibres,
which convert into a distinct tissue the external fibrous layer of the abdomen.
Hence a great variety in its dime'nsions, and a greater or less disposition to
strangulation in hernias formed by this passage.
In a well formed adult, the passage of the spermatic cord is an inch and
a half to two inches in length, measured from one of its openings to the other,
and three inches including the openings themselves. In some subjects I have
found it half an inch to an inch longer, while in others it has been so short
that the external border of its scrotal orifice was placed, as it were, opposite
the internal border of its abdominal orifice. In childhood it scarcely exists,
so that to escape without, the organs have only a ring to pass through instead
of a canal, as its two openings correspond and no distinct wall can be recog-
nized in it. This disposition is very easy to be conceived. While the angle
formed by the edge of the coxal bones is widening and enlarging, the spine of
tlie ileum is necessarily being removed from the pubis. 'The organs contained
in the cavity of the greater pelvis are drawn outwards to a distance greater
as the pelvis becomes larger ; whence it results that the opening in the fascia
iransversalis, which must follow this eccentric movement, leaves by degrees
the level of the ring in the external oblique which remains fixed on the pubis,
and these two orifices separate from eacli other, as two plates which are made
to slide over each other in opposite directions. This kind of movement, this
crossing of the two principal openings of the inguinal canal must be there-
fore much more marked in the female in whom t!ie cristse of the ilia are
usually very far apart, than in the male in whom the fibres retains through life
some of the characters which it possessed in infancy. It is easy to see there-
fore how the organs have at their first deviation more difficulty in traversing
the inguinal tract, after it acquires the form of a canal than while it remained
in the state of a simple ring, and that this difficulty is greater as these openings
become more distant from each other. One consequence to be drawn from
this fact is, that bubonocele should be more common in children than in
adults, in man than in women, and that every inguinal hernia developed in
youtli, which is kept reduced for some years, finding a canal or two walls
kept in contact by pressure, substituted for an annular opening, may be thus
radically cured ; while after the growth of the subject the reduction of the
hernia would not give the same chance of success. When it exists for a long
time, the presence of the viscera in tlie groin frequently brings back this track
to its primitive form, by enlarging the ring in the external oblique at the
expense of its external semi-circumference, while on the other hand it dilates
the orifice in the fascia trcmsversalis by pressing back its internal edge. It is
a kind of Z, which is to be made straight by drawing upon its two extremities,
so that tlie canal disappears in agreat measure, and often becomes a real circle
again» as in tire child. The inguinal tract and its pubic opening are cover-
606 NEW ELEMENTS OF
ed in front by cellular tissue and the skin. In the first, run some branches of
the cutaneous and of the superior external pudic arteries. Behind, it is also
covered with two layers ; the cellular tissue and the peritoneum are intro-
duced with the cord through the opening of the transverse fascia into the ingui-
nal canal and thus arrive in the scrotum, so that even without hernia there
is found in it, first, a prolongation of peritoneum lined externally Avith its
fascia propria; secondly, the vas deferens, the spermatic vessels, and what
is called the sheath of the cord ; thirdly, the tunnel -formed prolongation of
the fascia transversalis, which their parts bring with them supposing that any
power whatever has drawn them out from the interior of the abdomen.
Between the peritoneum and the posterior face of the canal, or in the
substance of the fascia propria, there are organs which itis important to notice;
the epigastric artery for example, which after rising from the external iliac at
the point where this vessel enters the crural canal, is directed inwards and
downwards, then upwards around the inferior and internal part of the cord,
or the inferior and internal semi -circumference of the abdominal orifice of the
canal, in order to reach the posterior face of the transversalis muscle, and
gain the external edge of the rectus, penetrating the fibres and terminating
above the umbilicus by anastomosis with the internal mammary and the
inferior intercostals. This artery, the volume of which is about that of a
small quill before reaching the abdominal muscles, gives off some branches
worthy of notice, although generally very small. It detaches one near its
origin which is soon divided into two branches, one of which engages in the
crural canal while the other runs towards the obturator foramen. A little further
off another is given off, which almost immediately enters the inguinal canal,
follows its internal wall, and is found in the scrotum in the substance of the
cremaster muscle ; this last branch ordinarily furnishes another, which runs
transversely behind the body of the pubis, and anastomoses with its fellow of the
opposite side. Lastly, a third arises a little higher up, is also directed trans-
versely inwards, and is of no consequence in surgery unless it attain a large
size and the hernia is formed inside of the epigastric. With respect to
inguinal hernia, the sub-pubic artery presents varieties of which the surgeon
should be aware. I do not refer to its arising from the iliac a little higher or
a little lower; this will be noticed hereafter ; but I cannot pass by in silence
two or three anomalies recently observed. In one v/hich has been drawn by
M.Hesselbach, this artery comes from the hypogastric, and instead of running
obliquely inwards rather tends to incline slightly outwards after going beyond
the line of the inguinal canal. In a subject examined by M. Michelet at the
Cochin hospital, it arose in the thigh from the internal circumflex, and ascended
to take its usual place between the peritoneum and the abdominal muscles.
Quite recently M.Lauth wrote to me that he had found two on the same side,
one coming from the hypogastric, the other from the external iliac ; one without,
the other within the line of the spermatic cord.
As it forms a certain prominence behind the fascia transversalis, the epi-
gastric artery gives rise at this point to a fold which divides the posterior wall
of the inguinal passage into two very distinct excavations, one of which I
propose to call the external iyigidnal fossetie, ^nd which corresponds to the
entrance of the canal ; the other which it is necessary to call the middle fossette
or depression, which is traversed by the organs in direct inguinal hernia, and
OPERATIVE SURGERY. 607
corresponds to the external part of the ring in the external oblique. Within
this excavation, and always in the substance of the fascia propriUy is found
another prominence, a mere vestige of the umbilical artery, which separates
the middle fossette, of which I have just spoken, from a tliird depression,
bounded inwardly by the fundus of the bladder or the external edge of the
rectus muscle, and which I would call the internal inguinal fossette in which
the viscera have also been seen to engage and form hernia.
The concomitant veins of the umbilical and epigastric arteries are in
general of too small a size to require any particular notice. However, it may
happen that a larger branch than usual may arise from the hypogastric or in-
ternal iliac, and ascend independant of the epigastric veins behind tlie
muscles, to reach the neighborhood of the umbilicus, and anastomose witli the
umbilical vein. Three anomalies of this kind have been published laterally
by Manec, Meniere, and Clement. The abdominal serous membrane extends
as far as the testicle, under the name of the tunica vaginalis, and represents
a canal, which after some time is closed and transferred into an impervious
cord, and in the end is blended with the surrounding cellular tissue, and converts
the tunica vaginalis into a sack without an opening, leaving at the same time
a tunnel -formed depression of greater or less depth at the posterior ring of
the inguinal passage. However, instead of being thus obliterated, this prolon-
gation may only contract and remain a little canal more or less dilatable until
adult age. As the spermatic vessels and the vas deferens are placed beneath
the peritoneum, and enter the inguinal canal supported by the internal and
inferior edge of its abdominal orifice, the prolongation must be naturally
situated without and a little in front of the spermatic cord, so tliat the vas
deferens is found within and behind. The spermatic artery is a little outwards
and in front. The two corresponding veins are seen one within, the other
without the artery, a little more in the rear and on the same plane with the
vas deferens. The filaments of the trisplanchnic nerve, situated a little more
superficially, are united with these several objects by means of loose lamellated
cellular tissue. Still further outwards is the peritoneal prolongation, then the
inguinal branch of the epigastric artery and the scrotal branch of the genito-
crural nerve. Thus around the cord, taken in its whole, there exist, first, a
canaliculate prolongation of the fascia transversalis, enveloping at the same
time a similar prolongation of ik^ fascia propria, the peritoneal filament and
the various constituent parts of the cord itself; secondly, the envelope formed
by the fibres of the internal oblique or the cremaster muscle ; thirdly, issuing
from the canal another sheath continuous with the circumference of the ring,
and which is but a prolongation of the fundamental cellulo-fibrous tissue of
the external aponeurosis of the abdomen ; in the last place come ih'&fasdd
superficialis and the integuments. Let us remark, moreover, that the whole
cord twists a little upon itself in passing through the inguinal canal, and that
the parts which at their entrance where behind and within, are in the end
found in front and sometimes even on the external side.
Surgical Remarks, — The external inguinal fossette is evidently the point
which offers the least obstacle to the viscera. It is through this therefore that
hernias pass most frequently and with the greatest facility, until latterly
these were the only hernias which occupied the attention of the faculty, and
it is only within thirty years that it has been deemed necessary to give them
608 NEW ELEMENTS OF
a particular name to distinguish them from those that follow another route.
The term external inguinal hernia, proposed bj Hesselbach, although gene-
rally adopted in France, is nevertheless not without its inconvenience. In
fact, hernias may be developed still further without, and it is well known
that Heister calls crural hernia, external inguinal hernia. After passing the
posterior opening of the canal, if the hernia meets too great a resistance at
the orifice in the external oblique, it may be kept back, and thus remain
in the interior of the passage. Lecat seems to have had an idea of a case of
this kind, and Mr. Lawrence and some other surgeons have positively
observed it since. It is this that M. Boyer names intra-inguinal hernia.
Arrested by the ring in the external oblique, and pushed by the action of the
muscles, the organs may double themselves outwards or upwards, and ascend
some distance in the very substance of the parietes of the abdomen, as Hes-
selbach seems to have experienced. Strangulation then will occur much
more readily, for the angle formed by the change of direction in the intestine
is of itself sufficient to produce it. It is only in cases in which the viscera
have cleared the cutaneous orifice of the canal, that hernia is really complete;
so that the name of incomplete inguinal hernia is more proper for it than intra-
inguinal hernia. However, a case reported by Mr. Lawrence, proves that
there may be at the same time a hernia without, and a hernia within the
canal ; or rather the hernia in this case was as it were divided into two parts
by the ring in the external oblique. Instead of penetrating through the
opening in the fascia transversalis, the organs have been seen to emerge
without this orifice, separating the fibres of the external portion of the
fascia, and falling afterwards as usual into the scrotum. M. Blandin asserts
that he saw an example of it on the examination of a dead body, and that
in the subject of which he speaks a fibrous band, two lines wide, separated
the neck of the hernia from the abdominal orifice of the inguinal passage.
In such a case the viscera would no longer have the/rtsa« transversalis for an
envelope unless they had carried it before them instead of separating its
fibres. J. L. Petit long since noticed another variety of inguinal hernia.
The organs escaped through a frayed portion of the external pillar of the
ring. Arnault saw the same thing in a subject in whom two hernias existed
at the same time, the one crural, the other a little more elevated, which
were only separated by a little fibrous band. Many practitioners have
disputed the existence of the variety mentioned by Petit, although Richter
has formally announced it since ; but a case observed latterly by M. Roux
at la Charite, leaves no further doubt on this subject. I have met with it
myself once in a young student of medicine. This young man had several
times perceived a tumor which appeared to be in the groin, and was soon
after returned. It was situated six lines exterior to the ring. Besides, when
it is recollected that most of the bands of the aponeurosis of the external
oblique leave between them a slight interval before attaching themselves to
the crural arch, it is readily understood how the viscera, if arrested within
by ajiy obstacle, may succeed in forcing one of these interspaces, and in some
measure create a new abdominal ring. Laeunec cites a much more remark-
able arrangement. He had to dissect the body of an individual who had die^l
of the consefjuences of a strangulated hernia. The organs had escaped by
the natural passage, and returned into the abdomen through an opening with-
OPERATIVE SURGERY. . , 609
out the aponeurosis of the external oblique. In a subcutaneous abscess Mr,
CofFart found a long portion of epiploon above the crista of the ileum. In
fine, J. L. Petit says, that he saw an inguinal hernia which was formed
through the internal pillar of the ring, leaving the ring itself entirely free.
The work of Juville on bandages contains a similar observation. However,
this may be ; and in all these varieties the epigastric artery remains on the
internal side of the neck of tlie hernia. Contrary cases form another species,
first described by Camper in 1759, afterwards by Cline in 1777, by Rouge-
mont, Chopart, and Desault, but the characters of which were not well
understood until after the labors of Hesselbach, A. Cooper, Scarpa, Law-
rence, and J. Cloquet. Instead of following the inguinal passage, running
obliquely inwards, as in external hernia, the intestines engage in the middle
fossette between the epigasti'ic and umbilical arteries, depressing, elongating,
drawing, or perforating the internal portion of the fascia transversalis, that is,
the posterior wall of the canal, and thus arrive directly in the ring in the
external oblique, and fall as in the preceding case into the middle of the
scrotum. As the epigastric artery remains externally, Hesselbach gave the
name of internal inguinal hernia to this species of rupture, which has latterly
been mentioned by several authors. Messrs. Lawrence and Hassenden have
observed it quite recently in a patient who died in St. Bartholomew's hospital.
Others have proposed to call it direct inguinal, in contradistinction to tlie pre-
ceding which they designate by the title of oblique. Some prefer calling it
ventro -inguinal ; but as all these denominations are more or less faulty, it is
probable that the one founded on the relations of the epigastric artery will
alone be preserved. It will also be seen that the spermatic cord is not in
the same relative situation in the one of these cases as in the other ; that ex-
ternal inguinal hernia must push it inwards and backwards ; on the contrary,
that internal hernia will almost of necessity tlirow it more or less outwards.
It appears from an observation of Wilmer and another of A. Cooper, that
hernia may also pass out by the internal inguinal fossette. It would be even
curious to know if this is not the place in which inguinal hernias of the blad-
der and uterus sometimes take place ? The fascia transversalis in its thickest
portion is then depressed or frayed as before. To clear the ring the organs
must follow an oblique direction from within outwards and from above down-
wards. I do not know what name it would be proper to give such a hernia.
C. Infantile Hernia,
In the adult inguinal hernia almost constantly pushes the tunica vaginalis
inwards and backwards. In very early life things are different, it is in front
that the ser<fll*htunic of the scrotum is situated. Hey, who first described this
species of hernia, called it by the name of hernia infantilis, and that in which
the tunica vaginalis remained behind, virilis. He met with it in several
subjects, particularly in a child sixteen months old. It was strangulated in a
child twenty -nine days old, whose case Mr. Hunt has since published, and in
another fourteen months old successfully operated upon by Mr. Lawrence.
Hernia of the vaginal sac. — If the tunica vaginalis is not closed above, the
organs will lodge there in preference ; and the hernia which in this case is in
immediate contac^t with the genital organs, takes the name of congenital her-
77
610 NEW ELEMENTS OF
nia. The name is incorrect. The species of disease it designates may be
manifested many years after birth. Hey, Dupuytren, Lawrence, and Roux
have shown tliat the testicle long retained in the ring^ may in descending at
twelve, fifteen, twenty or twenty-five years of age, be followed by a hernia
also enveloped by the tunica vaginalis. Moreover the viscera may descend in
this tunic, although the testicle had taken its place in the scrotum at a very
remote period. Hence, even a rupture ; the possibility of which would doubt-
less hardly be admitted by many surgeons, but of which I have observed two
cases which appeared to me quite conclusive. M. D. student of medicine,
twenty years old, was all at once seized with violent pains in the groin on
returning home one evening from walking with two of his companions; a
strangulated inguinal hernia became manifest. By the operation which took
place next day we found the intestine in contact with the testicle ; the stran-
gulation was produced by the external ring. The young man was completely
and promptly relieved. No previous hernia had existed, both testicles had
long been in their natural place. The tumor arose suddenly and immedi-
ately, became as large as the head of a foetus, and yet the sac was formed by
the tunica vaginalis. It would be in vain, it seems to me, in order to impair
the value of this fact, to endeavor to maintain that a portion of intestine
might be in the inguinal canal unknown to the patient, or that he was deceived
as to the descent of the corresponding testicle. M. D. had rather a certain
degree of leanness than embonpoint, and was in the habit of giving gi'eat at-
tention to every thing that concerned his health. It is therefore certain that
vaginal hernia may occur in adult man long after the descent of the testicle.
Besides, here is another case verified upon the opening of a dead body. In
1829 there entered my ward at the hospital St. Antoine a young wine mer-
chant, strong and of low stature, who the evening before had made a violent
effort in attempting to lift a cask. Being questioned in every way he con-
stantly answered that until then he never had a hernia. That for which he
came to seek assistance was of the size of two fists, completely strangulated,
and in the end required an operation. The intestine was contained in the
tunica vaginalis and in contact with the testicle. The ' debridement' was suc-
cessively performed upon the two orifices of the canal and the neck of the sac.
An intense peritonitis caused death on the third day. On opening the body
we found that the entrance of the vaginal membrane, frayed on tliree points
of its internal semi-circumference, was torn behind at is entrance into the
scrotum, that the inguinal passage preserved all its length and its obliquity,
and in fine, that to escape, the viscera had been obliged to distend and enlarge
forcibly the serous prolongation of the peritoneum, which was contracted but
not entirely obliterated. Since this period a third case of the same kind has
been published, obtained in the wards of M. Dupuytren. The young man,
eighteen years old, affirmed that the testicle of this side had descended at the
same time as that of the other. Another patient, twenty-one years old, who
on mounting a horse perceived a vaginal hernia appear, although both his
testicles were free, presents a fourth example. M. Lafond in his thesis says,
that he saw a young ecclesiastic about twenty years old, whose testicle had
not always been in the scrotum, suddenly seized with inguinal hernia, which
became strangulated and required an operation, and which also was in the
tunica vagiiialis. At first view, it seems difficult to conceive of a hernia of
OPERATIVE SURGERY. 611
this kind in an adult. However, by remarking, as Hunter and Callisen and
several anatomists since have observed, and as I have observed myself on two
dead bodies, that the scrotal prolongation of the peritoneum remains some-
times pervious during life under the form of a little canal, that at other times
also it only closes at its superior orifice in such a manner that the tunica
vaginalis ascends into the thickness of the abdominal parietes, this fact will no
longer be incomprehensible, and in nothing repugnant to reason, nor contrary
to the most simple anatomical notions.
From what has been said, hernia of the tunica vaginalis presents three dif-
ferent grades ; first, that which is formed in the fetus in the first moment
of existence, and this is properly congenital hernia, or the elytroid hernia of
birth ; secondly, that which arises from the arrest of the testicle in the ring,
preventing the tunica vaginalis from closing above, and allowing the viscerate
be engaged or even drawing them into it, when it finally descends, if it has
contracted adhesions with them, or by merely preparing a sac for their
reception : it is this variety, elytroid hernia of adolescents or adults to which
M. Dupuytren wished to call the attention of surgeons, and which Lawrence,
M. Roux, and others have noticeid; thirdly, that which I have just mentioned,
the predisposing cause of which is the incomplete obliteration of the cavity of
that portion of the peritoneum contained in the inguinal canal. Inquinal hernia
is much more rare in woman than in man, yet less so than is said or generally
supposed, and is not attended with exactly the same cliaracters as in the other
sex. The canal which receives it being longer, much less in width and filled with
the round ligament, which does not extend like the spermatic cord free beyond
it, but slightly disposes the abdominal organs to issue by this passage, and
much less, as the iliac fossa presents in its environs a much more favorable
point for their passage. However, it must not be forgot,that the inguinal opening
in young girls not being a canal but merely a simple ring, hernias of this de-
scription are quite as common in one sex as in the other. The round liga-
ment, in penetrating the groin and the extremity of the labia pudendi, is
sometimes accompanied with a peritoneal prolongation, known by the name of
canal or ligament of Nuck, which has been considered as analagous to the tu-
nica vao;inalis. The fact is, that the intestines have been seen engasred in
this appendix in young girls, giving rise to a hernia known by the name of
congenital hernia of girls. It is perceived, that in adult age the same thing
may happen if the ligament of Nuck remains permeable, but for the most part
the organs will pass in front and outwards, carrying witli them a real sac as in
men.
§ 3. Composition,
The sac of inguinal hernia seems to be most easily torn. It was upon an
inguinal hernia that the groom mentioned by J. L. Petit received a kick from
a horse, and the rupture in question was produced. The case of rupture of
the sac observed by M. Boyer, and published by Mr. Raymond, also related
to inguinal hernia. It is the same with that mentioned by MM. Diveux
and Plaignan(^, with a third case inserted in the Montpellier Collection of
Theses for 1817, and a sixth met with by M. Darbefeuille of Nantes, which
has this remarkable circumstance, that ^ej were able to confirm the fact by
612 NEW ELEMENTS OF
dissection of the dead body ; and a seventh published in 1826 by M. Breiden-
bach of Heidelberg. Not only may the sac of inguinal hernias be torn and
let the organs escape between the other envelopes of the tumor, but they may
be ruptured also on the side of the tunica vaginalis, into which it has fre-
quently opened, whether previously filled with fluid, that is, being the seat
of hydrocele, or in its natural condition entirely free. M. Dupuytren has
published several remarkable examples of this communication of the hernial
sac with the tunica vaginalis, which he has observed sometimes below, at
other times in front, and in some cases quite behind. It is evident that this
rupture is calculated to cause strangulation without preventing its being at
the same time otherwise developed, and which, if not foreseen at the time of
operating, would expose the viscera to be penetrated before recognizing the
sac. It is in inguinal hernia also that incomplete sacs are most frequently
met with, which is explained by the seat of the organs, which in escaping
from the abdomen, carry with them the adhesions by which they remain fixed
in their natural cavity. Although most of the causes of the errors pointed-
out in the article on the operation in general may complicate its diagnosis, it
is proper to say nevertheless, that ganglions, hydatids, and especially the adi-
pose layers or tumors which have been mentioned, are more rarely found on
its surface than on that of some other species of hernia. It should also be
remarked that the sac of inguinal hernia is that which contains usually the
most serosity, and is almost the only one in which it has been found to the
amount of pounds or pints. All the organs contained in the abdomen have
been seen in inguinal hernia; the coecum frequently forms it. A number of
cases prove even that it may enter the scrotum by the inguinal canal of the left
side, and also that the sigmoid flexure of the colon is found sometimes in
right inguinal hernia. The bladder penetrates it easily, as do also the ovaries
and the uterus. Moreover Ruysch and J. L. Petit have observed in it the
spleen, Reizelius the liver, M. Yvan has recently obtained at the Hospital of
the Invalids a case which proves that the stomach itself may descend into the
scrotum.
When the coecum engages itself gradually in the groin, and the hernia ac■^
quires a large size, it is not rare to see it fixed there, as in the iliac fossa, by
its posterior face, which may then become external and even anterior. This,
disposition Scarpa wished particularly to make known, and M. Sterlin (who
gives the name of acystic to the kind of hernia) and M. Colson had it in view
when they spoke of inguinal hernias deprived of their sac. It is evident
besides, that if in this case the incision should fall without, and be carried
upon an adherent part of the organ, there would be great risk of opening it,
and the sac would escape the search of the operator if the precaution was not
taken to look for it inwardly and in front. Although the sigmoid flexure of
the colon has most frequently a mesentery at its posterior edge, it happens
that in the scrotum it sometimes loses this fold, and finally becomes adherent,
there in the manner of the coecum. Pelletan, Lassus, and several other,
practitioners have published examples of this. A remark which must not be
forgotten is, that in hernia formed by the descending colon injections are
nol; received but in very small quantity, as M. Berard has noticed ; a pecu-
liarity which may be explained by the length of the portion of intestine
between the anus and the hernia. The bladder is the third organ which may
{
iibi:
.mm
OPERATIVE SURGERY. 613
present in the hernia with a sac more or less complete, the same as the
coecum. The ovary and the uterus offer nothing peculiar, unless it is that
their organs as well as t!ie bladder are unlikely to cause symptoms of stran-
gulation.
If the envelopes of inguinal hernia present fewer morbid anomalies than
those of other hernias, they have on the other hand a certain number peculiar
to themselves. Thus the spermatic cord contains adipose masses susceptible
of hypertrophy, capable of acquiring an enormous size, and of simulating
epiploic hernia. The serous or purulent cysts which are quite frequently
developed in it, are calculated to cause several symptoms more or less ana-
logous to those of strangulation. M.. Marjolin, M. Roux, M. Ouvrard of
Angers and others, have seen inflammation in the mass of the cord produce ajl
the symptoms of strangulated hernia, and M. Briot of Besancon speaks bf
an imposthumated ganglion which was taken for an intestinal tumor until the
close of the operation. M. Pecot mentions a fact which tends to prove tliat
the pus of a diffused abscess, and an abscess from congestion, which following
the inguinal passage makes a tumor in the groin, may deceive in the same
way. The strangulation in these cases presents all the varieties heretofore
noticed. In the most recent hernias, its seat is the fibrous ring in the externkl
oblique. Sometimes, however, it is formed by the opening of the fascia
transversalis^ as I found to be the case in an adult male. At this point, and
more frequently still at the neck of tlie sac, old hernias exist. In internal
inguinal hernia, the viscera having escaped through a simple ring and not
through a canal, the strangulation belongs almost always to the first or third
species, whether the tumors have passed through the natural ring, or through
a fissure in the internal pillar. If the hernias which pass through the external
pillar become strangulated, they may present the three varieties of ordin?iiy
hernia; but if the intestine be arrested in the inguinal canal, or in the sub-
stance of tiie abdominal parietes, the strangulation will only be susceptible of
the second or third variety. It was in inguinal hernia that Arnaud saw tlie
epiploon form a kind of ferule which strangulated the intestine in the centre
of the ring; and met with a loop of this organ so intimately adherent to the
parietes of the inguinal circle, tliat it seemed impossible for him to insulate
it. It was in this hernia in fine, that Pelletan, Lassus, as well as others and
myself have met with epiploic masses under every form, and those numerous
anomalies which have been noticed in treating of hernia in general.
§ 4. Operation,
As the integuments preserve in general a certain flexibility at this point, it
is almost always possible to form a fold for incising them. Whether one or
"le other method be adopted, the incision should extend a half inch or an
^h above the ring, and descend, unless there is a special contra-indication,
tlie bottom of the tumor, the great axis of which it should follow. This
Incision requires some precaution. The spermatic cord not having an inva-,
riable position, it would be easy in some cases to wound the vas deferens or
tlie spermatic artery, as happened twice to Hey. In external inguinal hero^
it has been found passing in front of the tumor, so as to be external wii^
arriving at its inferior part. Only some days since, I myself met with an
014 NEW ELEMENTS OP
instance at La Pitie, in a patient who had an enormous hernia. In internal
inguinal hernia, the same thing may happen but in an opposite direction ; that
is, the cord which is situated externally in issuing from the canal may gradu-
ally pass in front and then inwards to be continuous with the generative gland
which is below, and also on the internal side. No doubt that in cases of this
kind, the instrument will cut almost inevitably one of the constituent parts of
the spermatic cord as happened to Dr. Hey, and as it was easy to do in the
cases reported by Sclimucker, Camper, Le Dran, Boudou, M. Fardeau,
Scarpa, A. Cooper, Lawrence, Blizard, and some others. The tissues which
separate the integuments from the sac are to ^be cut therefore with care, and
in this respect at least it would be dangerous;^ follow literally the advice of
Louis, who directs them to be penetrated unhesitatingly, and in some sort at
a single stroke either with a sharp pointed probe or common bistoury. The
division of these intermediatory layers is performed according to the rules
laid down in the beginning. As to the sac, if it presents no wrinkle it is
most prudent to enter it below, in front, and a little externally. After open-
ing it widely upwards as far as the ring, the question is, whether it is indis-
pensable to prolong the incision quite to the bottom. Some think not, and
among others Dr. Hey, as well as Scarpa, fearing to touch the tunica vagi-
nalis which is found on this side, direct at least a half inch to be left infe-
riorly. In reality, it is altogether a matter of indifference which of the two
methods be adopted. When the hernia is congenital, the organs having
widened and distended more or less the tunica vaginalis beneath the testicle,
there are two obstacles to contend with in this point of view. If the sac is
opened in its whole extent, the testicle tends continually to escape from the
bottom of the wound, and may thus cause accidents. If the serous pouch is
only incised in its superior half the genital gland will be much more easily
retained ; but the pus, if it form, will accumulate in the cul-de-sac preserved
below, and may occasion other dangers. In this case therefore it would be
best to make a large opening, then bring the edges of the tunica vaginalis in
front of the testicle, and keep them there by one or more stitches.
On account of the vessels which it is' important not to injure, inguinal
hernia is one of those which are best adapted to dilatation, if this method is to
be employed in any case. Theory directs incision, the only resource
employed at present, to be performed in different directions according to the
species of bubonocele. For example, it. will be proper to direct it outwards
on one of the points of the external semi-circumference of the ring, for
hernias the neck of v^Kich is situated externally to the epigastric artery, that
is, all that pass through the superior orifice of the inguinal canal ; inwards,
on the contrary, for internal inguinal hernia, and directly upwards when an
epigastric artery exists in each side, as might have been the fact in the case
reported by M. Lauth. This variable indication explains the so opposite
councils given on this subject by the most cojnmendable authors. Sliarp,
Lafaye, Pott, and Sabatier direct the incision to be made upwards and
outwards, because the epigastric artery is commonly found on the inside ;
Verduc, Garengetrt, and Heister, on the contrary, direct it to be made inwards,
a»d Bertrandi, who saw the incision outwards produce a hemorrhage
fram the division of tlie epigastric artery which caused the death of tlie
patient, gives the same advice. In fine, it was from fear of finding this
OPERATIVE SURGERY. ^15
artery on either side that J. L. Petit, before Rougemont and Autenrieth,
Messrs. A. Cooper, Scarpa, Richeraad, and Dupuytren who follow the same
practice, directs the incision to be made directly upwards. Desault and
Chopart had, it is true, already remarked that the artery is on the inside
when the cord is found behind or on the internal side of the tumor, and on
the outside in the contrary case. But to fix opinion upon it, all the anatomi-
cal knowledge at present acquired by the immense majority of operatoris
was necessary. To say that the incision should be made outwards when the
hernia is external, and inwards when internal, would be of no avail unless it
were more easy to distinguish these two varieties of the disease from each
other. Besides when there are two epigastric arteries, or when this vessel
arises from the obturator at a certain distance from the external iliac, it may
very readily be found within the internal inguinal hernia, as is usually
remarked in external inguinal hernia. The external epigastric artery in
the subject observed by M. Lauth, might have placed itself external to an
oblique inguinal hernia. In consequence of this uncertainty, Messrs. Cooper,
Scarpa, Richerand, and Dupuytren justly prefer the method of Petit or Rouge-
mont. By cutting directly upwards, say they, whether the artery be without
or within, whether two or only one, whether the hernia be internal or external
is of little consequence, no hemorrhage is to be feared, for this instrument
divides the tissues in the known direction of the vessels. One objection
presents, nevertheless, which is, instead of following a line parallel wdth the
axis of the body the epigastric artery is directed obliquely inwards and
upwards to reach the umbilical region, passing above the internal inguinal
hernia ; while in external inguinal hernia I have seen it bent downwards
and inwards so that it formed in some sort a semi-circle, the superior extre-
mity of which might be easily reached by a perpendicular incision. Then as
it seldom fails to be more or less displayed by the origin of the tumor, it
cannot be known whether it is really vertical or oblique in either direction.
It would be equally possible to wound it by cutting directly upwards. I will
add, that in internal inguinal hernia the pubic branch furnished by the epigas-
tric would almost necessarily be cut, and in cases where its size is abnormal a
troublesome hemorrhage would result, as seems to me to have occurred in
the two observations noted by Mr. Lawrence, according to the commentaries
of Duncan and Home. No method completely protects from hemorrhage,
yet a wound of the epigastric artery is extremely rare. On what can this
depend ? First upon its being pushed aside by the neck of the sac, so that it
is almost always situated two or three lines from the constricting circle, and
most commonly this is the greatest extent given to the incision ; secondly,
when the strangulation is produced by the ring of the external oblique, the
incision is made on a circle too far from the artery in question, to give
rise to apprehensions of wounding it ; whence it follows, that in a strict
analysis the incision may be made in every direction without danger, pro-
vided too great an extent be not given to it, and thus the successes obtained
at Vienna in the commencement of this century by M. Rudthoffer, who
always cut inwards like Bertrandi, are not to be thought surprising. If we
add that internal inguinal hernia is very rare, and that at present the outward
incision is preferred in the great majority of cases, it will be understood why
hemorrhage as a consequence of celotomv is so uncommon. However, as
616 NEW ELEMENTS OF
it has been observed in several subjects, it is proper still to think of the means
of avoiding it. But in every strangulation caused by the inferior opening of
the canal, tlie incision from before backwards with a convex bistoury carried
on the end of the finger as directed by Bell, whether imitating Messrs.
Colson and Dellouey or M. Dupuytren, or, which is still better, using the
point of a straight bistoury protected also by the finger, and which cutting
from the free edge of the ring to a point more or. less distant from its circum-
ference, will be entirely free from all danger, since by conforming to these
principles the instrument only penetrates as far as the posterior face of the
fascia transversalis. In other cases, the debridement multiple, either with the
straight probe pointed bistoury or the curved bistoury, allowing only ofle or
two lines of depth to each incision, is well calculated if I mistake not to
render a lesion of the epigastric artery almost impossible in any direction. '
If notwithstanding all these precautions the artery has been wounded, of
which Gunz heard too cases cited at Paris, as Bertrandi has proved by opening
the body, and of which Richter, Leblanc, Hey, A. Cooper, Scarpa, Lawrende,
&c. have quoted cases, what is to be done ? Mr. Law rence says that he found
the epigastric branch completely divided on the bc-dy of an individual operated
on for strangulated inguinal hernia, whose death had been produced by anotlier
cause. In a second case, the hemorrhage was suspended by a syncope, and
the patient completely recovered ; it remains however to inquire whether the
blood really escaped from the epigastric artery. I have seen on a subject
^ho had died in consequence of a penetrating wound of the abdomen, a com-
plete division of this vessel from which the hemorrhage had been but trilling
/and was spontaneously arrested. It would then appear to be possible that
i this wound might take place frequently unknown to the surgeon. The ligature
carried over the root of the artery as directed by Bogros, or through the wound
by means of the several instruments proposed by Arnaud, Schildner, Richter,
Desault, and many other practitioners, is too difficult of application and otfers
too little certainty to induce the attempt. It would be better to carry beyond
the ring a kind of chemise or little sac of fine linen, the bottom of which is
to be filled with soft charpie so as to form a tampon of greater or less width
and thickness, by means of which the parts may be compressed from behind
anteriorly, or from the peritoneum towards the integuments. It was thus that
Mr. Hey and Boyer acted in the successful cases reported by them, or in
their name. "
Reduction, — This hernia is the most common, and it is this which most
frequently contains the small intestine and the adherent parts of the large
intestine; it is this that the direction given by M. Dupuytren applies, that if,
as it sometimes happens, a membrane of new formation bridles the two ends
of the visceral loop so as to prevent its elongation, it is necessary to destroy
it. The best mode of returning the liquids, and the matters contiiined in this
loop, is to embrace the mass with the palms of both hands, and press it gently
until it is nearly empty. Here also care must be taken not to engage it
between the peritoneum and the fascia transversalis, or in the substance of the
abdominal parietes, for it is in. this species of hernia tliat Le Dran, Caliisen,
De la Faye, Sabatier, Pelletan, Lassus, Hesselbach, M. Delmas, Mr. Law
rence, and myself, have observed the accident just noticed. No where in fact
does the hernial passage present greater length, no where is there found so
mt
?Wf
OPERATIVE SURGERY. 6l7
much laxitj in the cellular tissue which unites or separates the peritoneum
from the muscles and the several constituent layers of the abdominal walls,
no where in fine, are bands more frequently found behind the ring, which are
formed by adhesion of the coecal appendix, a prolongation of the epiploon, by
an accidental band, &c. It was in this moreover that Dr. Hey saw the sac
divided horizontally into two distinct pouches by epiploon, an anterior one
containing only serosity, and a posterior in which was. contained the intestine.
In a word, there is perhaps not a single anomaly or degeneration of the di-
gestive organs or epiploon which has not been observed in the inguinal hernia.
It is this besides which has presented those appendices in the form of a finger
of a glove observed by Ruysch, F. de Hilden, Mery, and especially by Littre,
and which belonged to a more or less elevated point of the ileum. When
inguinal hernia is old and of immoderate size, as it is rare that the displaced
viscera have contracted mutual adhesions which it is difiicult to destroy, and
are not in a measure agglomerated so as to represent in certain cases a mere
fleshy mass, reduction ought not always to be attempted. If in this case the
hernial envelopes have been divided in their whole extent only the free parts
are to be returned, the rest is left without; the whole is to be covered with
compresses soaked in emollient fluids, and the horizontal position, which the
patient is to keep, brings them gradually within the ring if not into the inte-
rior of the abdomen itself.
It is in this variety in particular that Ravaton, Monro, Cooper, Crawther,
Lawrence, Boyer, and Scarpa, after J. L. Petit, direct the incision to be made
without, passing through the peritoneal layer, in the mode which M. Raphel
supposed that he had originated, but which he only combined with the idea of
Bell on removing the stricture in general. An incision is then made of some
inches in length at the root of the tumor, to reach by degrees the neck of the
sac without opening it. A grooved director is then introduced between this
neck and the ring, which is then divided conformably to the rules already laid
down. The strangulation being relieved, if the viscera can be returned into
the abdomen without too much difficulty, reduction is to be attempted imme-
diately. In the contrary case only those which yield readily are to be
returned, and the rest supported or retained by a suspensory or properly
arranged bandage. If after incision of the ring the strangulation remains,
the neck of the sac should be perforated, a probe pointed bistoury introduced,
and it should be divided with the usual precautions. The wound being closed
by adhesive strips, generally cicatrizes after several days. In ordinary cases,
when the organs are reduced, the sac is sometimes so movable, so slightly
adherent, that it is possible to detach it, and form it into a small plug, as
Garengeot says, and pack it into the ring or excise it.
Without returning to what I have said on this subject in the preceding
pages, I cannot dispense with remarking, that if it is determined to follow it
in inguinal hernia, it is necessary previously to be assured of the situation
occupied by the vas deferens and the spermatic vessels. When inguinal
hernia is direct, the incision should be parallel with the axis of the body. It
should be oblique from above downwards and from without inwards, on the
contrary when the tumor is external and of small dimensions ; but when it is
very large, it is found very well to give the incision the form of a half moon
very much elongated, the convexity of which shall look upwards and inwards.
78 " ir
-If
618 NEW ELEMENTS OF
If the operation is performed on a woman, there will be no precaution required .
with regard to the cord. If in this hernia the ovary is retained near the ring,
or has descended into the labia majora, of which Priscien, Veyrat, Pott, Lassus,
Haller, M. Lallemand, and M. Deneux, have reported examples, and if the
symptoms appear to depend in any degree upon its presence in the ring, th^^
wisest plan would be to remove it. The uterus and the bladder may be
reduced the same as the intestines, or will not fail to be spontaneously reduced
in the end. Supposing the operation to have been performed to remedy
symptoms produced by strangulation of the cord, observed also by M. Roux,
the incision once made, nothing further is required. In case of hydatids and
adipose tumors, excision of the morbid parts is to be performed; as also for
lymphatic ganglions, if they chance to be developed in the inguinal canal.
A more embarrassing case than all these is that which arises from the
presence of the testicle in the interior of the ring itself. Almost always in
this case the genital gland is altered either in its conformation or its structure.
If it is excised, the man is deprived of an important organ ; if strangulation is
merely removed, and the testicle cannot descend, the same symptoms may be
reproduced, and the patient only receive temporary relief from herniotomy.
Before the operation it will be the more difficult to determine with certainty;^
for a real hernia maybe manifested in the place of the testicle as in a monorchid,
of which M. Fayes has given an example. The practitioner is therefore to
determine by the disposition of the parts, and the peculiar circumstances in
which the individual is placed, on the plan which it is reasonable to pursue.
ARTICLE II.
Cmral Hernia.
§ 1. — Anatomical Remarks.
Crural hernia was scarcely distinguished from inguinal, until the times
of Barbette, Lequin, Nuck, and Verheyen. Its natural seat is the fold of the
groin, and the opening which gives it passage is known as the crural ring or
canal. By its superior edge, Poupart's ligament is continuous with the
aponeurosis of the external oblique in the direction of the skin, and the fascia
transversalis in that of the peritoneum, and is continuous below with the
fascia lata towards the thigh, and the fascia iliaca towards the abdomen- At
the middle of the ligament of Fallopius the crural aponeurosis separates into
two layers. Its superficial lamina follows the course of the ligament until
near the pubis, then separates from it, and is applied upon the pectineus
muscle, and continuous with the fascia pelvica. The first, described under
the name of the falciform process by the English surgeons, may be compared
to a triangular lamina ; of its edges, the superior unites with the ligament, the
external is continuous with the primary aponeurosis, and the inferior or in-
ternal is free and more or less concave. The second, generally thicker, is
continuous inwards and upwards with the expansion of the external pillar of
the inguinal ring, or with Gimbernat's ligament, of which we shall speak
presently. An oval opening, with its base inferiorly bounded by the free edge
of the preceding layer, results from this disposition^ and through this the
internal saphena vein joins the femoral. Its plane looks inwards, forwards,
OPERATIVE SURGERY. 6lS>
and a little downwards. About the middle of Poupart's ligament, the iliac
aponeurosis dips down in the same manner as the inferior layer of the fascia
lata, and thereby leaves between it and this ligament a kind of elliptical
opening, which is the crural ring proper. This ring deserves all the attention
of the surgeon. A small vertical septum usually divides it into two parts, the
one external, in which is found the femoral artery and vein, the artery without
and the vein within, filled only by cellular tissue and a lymphatic ganglion.
To sum up ; the anterior vacancy in the coxal bone is converted into two large
foramina, by the ligament of Fallopius. This ligament, which is single until
the fascia iliaca and the inferior process of the fascia lata separate, so as by
being depressed towards the pubis, to bind the muscles and nerves of the iliac
fossa, seems in fact, to bifurcate in order to form the crural canal, and thus
separate the femoral vessels from the parts I have just described. Its hori-
zontal branch gives rise, in approaching the symphysis pubis, to a membranous
expansion, which is fixed to the crest of the pubis inclining a little towards
the thigh, so as to become continuous with the inferior lamina of the /«5aa/a^a,
and which is known by the name of Gimbernat's ligament. Continuous above
with the external pillar of the abdominal ring, fixed below and behind to the
crista ileo-pectinea, it presents outwardly a concave or crescentic layer, which
reacts in an important manner upon the organs concerned in crural hernia.
Thus this canal is formed, externally by the separation into two lamina of
the ligament of Fallopius and the fascia lata. The falciform aponeurosis,
which is shorter as it approaches its internal side, constitutes its anterior
wall. Posteriorly it is formed by the muscular layer of the crural aponeuro-
sis. Interiorly it has really no wall, and is bounded by the free or sharp
edge of Gimbernat's ligament. The femoral artery and vein fill its external
half or third, and conceal its longest wall, and cause its inferior orifice to
limit exactly its extent below. In its natural state this canal is filled with
cellular tissue, which forms a communication between the fascia propria, or
the lamellated lining of the peritoneum and the fascia superficialis, or the
subcutaneous layer of the groin. A lymphatic ganglion, often of consider-
able size, usually closes its entrance, while its crural orifice is as it were
curtained by a lamella of more or less density perforated for the commu-
nication of the superficial lymphatic ganglion, with the deep seated ganglia
of this region. The saphena embraces the base of its orifice, the two extre-
mities of which at the point seem to cross, passing one before the other, so
that the posterior is continuous with Gimbernat's ligament, and the other
with the pubic extremity of the arch. In passing through the crural canal,
the hernial sac, already lined by the fascia propria, carries before it and
appropriates the major part of the cellular tissue which is found there, is
enveloped at its exit with \he fascia superfcialis and the whole subcutaneous
cellulo-adipose layer, carries before it by the same reason downwards and
inwards or outwards the lymphatic ganglia^ which in some cases it only
raises up, and which thus remain upon the surface of the tumor. Having
arrived without, the hernia tends much more to the external and superior part
thati in the opposite direction, which is owing to the greater adhesion of the
fascia superficialis inwards and downwards than towards the spine of the
ileum, and the external portion of the ligament of Fallopius. It is thus that
the hernia has been seen to return to within two or three. inches of its exit in
620 NEW ELEMENTS OF
the direction of the ileum. Examples of it have been reported by Arnaud,
and more recently by M. Larrey. The sac runs along and without the
femoral vein and artery. At its superior part it is in contact with the origin
of the epigastric artery ; which crosses its anterior and external portion more
or less remotely in its passage to the peritoneal face of the abdominal mus-
cles. In front, it is concealed first by the ligament of Fallopius, and a little
further down by the falciform process of the fascia lata. Posteriorly, it is
supported by the crista and triangular surface of the body of the pubis, the
pectineus muscle, and more immediately by the posterior lamina of the crural
aponeurosis ; in fine, its internal side is embraced by Gimbernat's ligament.
It must be remarked, besides, that in the male it is crossed obliquely by the
spermatic cord, from which it is separated only by Poupart's ligament.
The epigastric may arise an inch or an inch and a half higher than usual, and
also may be furnished by the femoral artery below the ligament of Fallopius ;
which in the first case may cause this branch to be thrown on the internal
side of the hernia instead of remaining externally, and in the second may
bring the incision on some point of its external half, and almost inevitably
cause its division. A second and more remarkable variety is one which X
I have already described, in which the epigastric artery arises from the obtu-
rator at more than an inch from the external iliac, as seen by M. Hesselbach,
and of which I also have met with an example. In this case no doubt the
crural hernia would be external to it. The same would occur if the epigastric
arose from the hypogastric, as I have seen it. A much more fearful arrange-
ment might still be observed, if the hernia were formed in persons having two
epigastric arteries on the same side, one coming from the iliac the other from
the pelvic artery, as seen in the individual mentioned by M. Lauth. In man,
especially, the neck of the sac would then have the pelvic epigastric within,
and the iliac epigastric without, and the spermatic cord in front. A last
anomaly which has not as yet been noticed, I think, is that for the knowledge
of which we are indebted to M. Michelet, in which the internal circumflex of
the thigh arises from the epigastric itself. The artery in this case may be
found in front of the body of the hernia, crossing obliquely outwards and
inwards, and reaching the adductor muscles of the thigh. But the variety
of which most has been said, is that in which the obturator and epigastiic
arise by a common trunk from the external iliac ; this is in fact the most
frequent. The examinations which I have been enabled to make on several
thousands of dead bodies, either in the hospitals, the dissecting theatres, or
the school of practice, will not allow me to say that it happens once in three,
five, or ten times, but about once in fifteen or twenty. It is moreover a fact
more simple than is imagined. Before birth the obturator artery almost con-
stantly arises by two roots, one coming from the hypogastric, the other from
the epigastric ; but the epigastric root becomes soon obliterated, the hypogas-
tric remains, and definitely forms the vessel. If the contrary happens, the
anomaly in question is observed.
Many practitioners have thought that in this case the neck of the crural
hernia would have the epigastric artery external to it, and the obturator in
front and within, so as to be surrounded with an almost complete arterial
circle. As tlie epigastric trunk is placed between the peritoneum and the
fascia transversalis or the ligament of Fallopius, if the obturator comes from
OPERATIVE StIRGERY. 6QrV
it, it is necessai'ily situated in the substance of the fascia propriay and in
order to reach tlie sub-pubic foramen, it must follow the inferior semi-circum-
ference of the crural canal. The viscera in escaping, having from this cause
almost necessarily to throw it back, do not appear to run any risk of bringing
it on their anterior face. I have not moreover as yet learned that a wound of
it has been verifietl by examination of the dead subject, although it is said
to have occurred several times in persons who have survived.
For the sole reason that the iliac artei-y in entering the ring divides this
opening into two parts, and that the epigastric artery is detached from its
internal or anterior part, there must exist another point externally of little
resistance. By introducing the finger it is soon ascertained that it is really
possible to pass thereby from the interior to the exterior of the abdomen;
whence it seems to result that the hernia must sometimes be formed on the
iliac side of tlie epigastric vessels. An external crural hernia therefore, and
an internal crural hernia may be admitted. Only a single example however,
has been given of late, and that by M. Cloquet; Arnault, most of the patholo-
gists of the last century, Sabatier, and M. Walthier say, indeed, that in
issuing from the abdomen the intestine passes obliquely inwards on the an-
terior face of the crural vessels, and consequently leaves it to be understood
that the epigastric artery remains on the internal side of the neck of the sac ;
but on this subject they are confined to mere assertion, and there is no proof
that they positively established the fact by dissection. Femoral hernia is not
enveloped with as many laminae as bubonocele. There are found only the
peritoneum, the fascia propria y and the/ascia superjicialis, blended miom. cel-
lular-adipose mass, and the integuments. It is in this layer, intermediate to
the skin and serous covering, that*%*e found lymphatic ganglions, sound or
diseased, enlarged, indurated, swollen in any manner, inflamed, or suppurated ;
hydatid cysts ; abscesses, hot, cold, or from congestion, which sometimes
surround a crural hernia, so as in some cases to render the diagnosis so difficult,
and the operation so delicate. It was there, no doubt, that the pus collected in
the two cases of cold or congestive abscesses mentioned in the thesis of M.
Bayeul, which were mistaken for hernia. In this layer also the veins which
return from the abdominal integuments are observed as well as the corres-
ponding arterioles, and where are developed the tumors or adipose layers
which I have pointed out in treating of hernia in general. As to the saphena
vein, although situate in the intermediate layer, it is always thrown behind and
below the tumor.
The opening wliich gives passage to crural hernia is so firm and solid, the
tissues which receive and envelope it at the thigh have in general so much re-
sistance, that it rarely acquires much volume. It is compelled to pass through
an orifice deeply situate, and is liable to be stopped in the canal itself either
above, at its middle, or at its femoral orifice, and its existence is therefore often
difficult to be ascertained in fat subjects, particularly in women in whom it is
so frequent. The same causes, as maybe supposed, render the operation more
troublesome than in inguinal hernia. It is besides owing to the narrowness of
the passages and their want of extensibility that this hernia is so easily stran-
gulated, and so difficult of reduction when there is the least constriction. In
its interior, the same organs have been found as in the neighboring hernia, with
the same anomalies, and the same pathological alterations. It iS subject to
fc
622 NEW ELEMENTS OF
remark however, that its sac, generally thinner than that of oscheocele, con-
tains usually but very ^ttle serosi ty, sometimes but a tew drops, and often
none at all. Nevertheless there have been cases in which several ounces were
found within it, tliat is an excess as I have noticed in supra pubic hernia.
§ 2. Operation,
Celotomy of the hollow of the groin requires more precautions than that
of the scrotum; first, because we more readily reach the sac when no com-
plication exists, and because in the contrary case we have all the diseases that
may be manifested in this region to distinguish from the hernia itself; again,
because the sac being very thin and often blended by its external face with the
surrounding cellular tissue, is liable to be opened before it is perceived, and
containing scarcely any serosity renders lesion of the intestine very easy ; in
the third place, because we must go to a great depth, and incise parts almost
necessarily surrounded with bloodvessels.
The incision of the integuments should and may almost always be made in
the direction of the inguinal groove, and of the great diameter of the tumor at
the same time. A simple incision is in general sufficient; however, if the
hernia is very large and there is difficulty in laying bare its neck, there is no
objection to converting this first division into a T incision in the manner of
M. Boyer, by making another cut with the bistoury on the superior lip,
or on the other, as there may be occasion to lay bare the internal or
external side of the canal.
There is no reason why in every case a T incision should be made, the ver-
tical branch of which is turned upwards, as directed by Sir A. Cooper, in
order to run no risk with the internal saphena vein. The crucial incision
directed in the Clinique of Pelletan, which M Dupuytren has often employed,
can be but very rarely indispensable. But if there is good reason to have
recourse to it, the fears of the English surgeon in respect to the saphena
should by no means be an obstacle, for this vein is always placed beneath and
behind the hernia. After opening the sac, it is as rare that we are to reduce
the organs without incision as M. Boyer remarks, as it is common to see the
intestine excoriated, ulcerated, or perforated in the portion which suffijrs the
constriction. The stricture being in general caused by the sharp edge of the
falciform process of ihe fascia lata, or the concavity of Gimbernat's ligament,
the circle embraced by these two parts must first be examined. Ulceration
existed in this place with the patient operated upon in my presence by
M. Wessely, with a woman upon whom I operated myself, and with
several individuals operated upon by Rona, Boyer, Lawrence, &c. The
attempt must not be made, therefore, to reduce the parts before bringing out
the portion which was contained in the canal; consequently, incision
without opening the sac is not applicable in this case. On account of the
danger of cutting the structure in crural hernia, dilatation has been thought
of. Externally it is said you have the epigastric artery, above the spermatic
cord, within you will wound the obturator if it arise from the epigastric.
Happily these dangers are much less in practice than in theory. Sharp cut
outwards and upwards, and although he operated on a great number of subjects
sve do not see tkit he ever happened to wound the pudic artery, the tying of
OPERATIVE SURGERY. 623
which by the way he considered very easy. Pott cut upwards, and the spermatic
cord does not appear to have been wounded by him. Since Gimbernat, most
surgeons cut inwards, and there is no proof that the sub-pubic branch has ever
been divided in this manner. It is sufficient however that the thing be possi-
ble, not to neglect the means of avoiding it with most certainty. The process
of Sharp is evidently the worst of all. M. Dupuytren, who appears to have
reproduced it and conformed to it for a long time in his practice, has modified
it in such a manner that it is no longer attended with the same dangers. This
surgeon carries the edge of his curved bistoury reversed on the external edge
of the opening for the saphena between the laminse of the fascia lata, so that
he cuts the tissues from before backwards or from below upwards, and thus
desti'oys the strangulation before arriving at the place occupied by the artery
to be avoided. In this, his method has but one inconvenience ; which is, that it
is not applicable to a stricture depending on the neck of the sac. It may also
be applied upon every other point of the ring ; but as the incision of the falciform
process generally relaxes the whole extent of the opening, it has the advan-
tage of being sufficient in the greater number of cases. The incision upwards
and a little inwards is not formidable in woman when there is no vascular
anomaly ; in man on the contrary it may lead to a wound of the spermatic ves-
sels. Arnault says he was witness to an operation in other respects performed
very well, and of which the patient died in consequence of hemorrhage from the
spermatic artery. Scarpa took pains to demonstrate that it is almost impossi-
ble to cut in this direction without incurring the danger pointed out by Arnault.
Experiments tried by the latter in presence of Bassuel, Boudou, &c., and the
plates of the learned anatomist of Pavia tend in fact to prove that by cutting
the ligament of Fallopius from below upwards to the extent of two or three
lines, the spermatic artery is almost inevitably wounded. Happily, chance
or circumstances deceived these observers, and their fears are really exag-
gerated. First, it is not correct to maintain with Scarpa that the spermatic
cord rests immediately on the bottom of the gutter of Poupart's ligament.
Some muscular fibres, and a cellulur tissue sometimes quite abundant, usually
separate them. It is not under the edge of the internal oblique but rather
between its fibres that the cord passes. Besides, this ligament has four to five
lines of height in the internal half of the ring. Outwards it would be entirely
divided before running any risk, and this is never indispensable. When
we give from six to eight or ten lines of extent to the incision, the
danger which alarmed Scarpa and other modern surgeons cannot be denied to
exist ; but at the present day, as the cut is never more than two or three lines
in length these fears are without much foundation. The case reported by M.
Lawrence would be moreover further proof of this, for notwithstanding the
complete division of the external pillar of the external oblique, the cord was
not touched in the subject of whom he speaks. Besides, is it very true that
an artery of as little importance is that which goes from the epigastric to the
scrotum, or that the spermatic itself is capable of occasioning so dangerous a
hemorrhage ? It is outside of the peritoneum too that it would be found divided,
and on this supposition it does not appear that, either by means of a ligature
or suture, plugging or compression, it would be very difficult to obliterate it.
And might not Arnault have been deceived as to its being hemorrhage under
which the individual sunk whose case he relates ? Were there not in this case
some particular circumstances which he neglected to mention r
624 NEW ELEMENTS OF
Gimbernat, whose labors had already been made known at MontpeUier in
1788, by M. Purcel y Venuales, having studied better than his predecessors
the anatomical arrangement of the passages, thought that the danger in the
process of Sharp and lesion of the cord might be avoided by cutting inwards.
His end being to separate with the bistoury, curved or straight, the triangular
expansion to which his name has been given, from the inferior edge of Pou-
part's ligament he carries the instrument to the superior part of the internal
semi-circumference of the ring, and then directs it obliquely inwards and
downwards as for reaching the pubis by following the direction of the exter-
nal pillar of the inguinal passage. In this manner the epigastric artery and
the spermatic vessels are certainly avoided. Scarpa and the moderns add
that it will be the same with respect to the obturator when it comes from the
supra-pubic artery, since the incision follows in some measure the same
course as the vessel ; but to obtain this advantage it will not be necessary to
act through Gimbernat's ligament at its middle, and still less to cut obliquely
from below upwards, keeping close to the pubis as a considerable number of
French surgeons understand and daily practise. Although it is preferable,
yet what we have said above of the varieties sometimes presented by the
epigastric and obturator vessels, proves that this method does not entirely
secure us from hemorrhage. It would even render it very liable to occur, if
the epigastric artery, or one of them, if there are two, should be found to the
inner side of the neck of the sac, and also in case a large branch coming from
the internal iliac or hypogastric vein should ascend also on the inside of the
neck of the sac, as M. Manec has pointed out in his thesis, and wliich M.
Meniere says that he has seen. In this case, incision upwards may be the most
certain to prevent hemorrhage, especially if, as M. Manec directs, the bistoury
be carried upwards and without the ring, in order to divide Poupart's liga-
ment partially and perpendicularly to its axis. Some condemn the incision
inwards as endangering the uterus and intestine in pregnant women, or the
bladder when distended with urine. Hey, who quotes a case of the latter
description, and who has never divided, nor seen divided, the epigastric
artery, concludes therefrom, notwithstanding the remarks of Sir A. Cooper,
that it is best to cut the ring upwards and outwards according to the practice
of Sharp ; but it is clear that a prudent surgeon will always avoid without
difficulty the urinary reservoir and the gestatory organ, so that if the method
of Gimbernat were attended with no other dangers the objections of the able
surgeon of Leeds would be of little weight. The femoral circumflex artery
coming by anomaly from the epigastric, or vice versa, so as to pass in front of
the hernia, is the only one which cannot be avoided, unless discovered in lay-
ing bare the sac ; happily the wound in it would be necessarily near the sur-
face, and it would be easily seized and tied. On the whole, the most certain
method of performing this incision without danger, is, in my opinion, to cut
successively on several points of the sharp edge of the crural canal, as shown
by Scarpa, M. Manche, and M. Dupuytren (unless the septum crKrale, that
is, the process of the fascia propria which closes the canal superiorly, have been
transformed into a fibrous circle, the possibility of which is pointed out by M.
J. Cloquet), and only to the extent of two or three lines for each division.
The anatomical disposition of this passage, and the operations which I have
already performed, induce me to believe that the stricture in this place is
OPERATIVE SURGERY. • 625
always produced by the free edge of the falciform, process, the concavity
of Gimbernat's ligament or the neck of the sac, and scarcely ever by the
superior ring; so that generally it should be sufficient to incise its inferior
opening at one or more points to produce a proper relaxation, without carry-
ing the bistoury into the abdomen. If this doctrine is not adopted, the inci-
sion should be made according to the principles of the surgeon of Madrid, or
from below upwards, if we could cease to be tormented wdth the apprehension
of wounding the spermatic cord.
A celotomy recently performed at La Charite, proves nevertheless that the
incision inwards may be followed by hemorrhage. Arterial blood issued in
great quantity from the wound. An assistant was obliged to carry his finger
to the bottom of the ring, and compress from behind forwards. M. Boyer
immediately had recourse to a little sac of linen carried even into the iliac
fossa, which, being then filled with charpie, was substituted for the finger of
the assistant. This apparatus was not removed before five days. Hemorr-
hage did not reappear, an*d the patient was completely restored. It would be
difficult, I think, to tell what artery was here wounded. Was it the obturator
coming from the epigastric? It would be necessary to admit that it had
passed above the neck of the hernia. Was it the epigastric or an abnormal
epigastric as in the case of M. Lauth? Might it not rather be the small
branch naturally given off by the supra-pubic artery behind the symphisis,
arid which being more developed than usual, gave rise to this accident ? On
this subject it is perceived that there can only be suppositions.
The relation of the vessels with the neck of the sac w411 render the mistake
so dangerous, if, as seen by Richter and A. Cooper, an inguinal hernia be
taken for a crural hernia, and reciprocally, that the surgeon should never
lose sight of it. A merocele pushed in front of the inguinal canal by old
cicatrizes of the hollow of the thigh, as in the case reported by M. Boulu in
the name of M. Marjolin, might easily give rise to error on this point; and
incision outwards, as for bubonocele, would endanger the epigastric artery.
M. Roux, who incises like Gimbernat, had occasion to esteem himself very
fortunate in ascertaining by dissection, that the inguinal hernia, which he had
taken for a crural hernia, was formed within the artery; that is, was direct
or internal. If in a similar case, Pelletan had not discovered his error on
arriving at the viscera, it is very probable that chance would not have served
him so happily, and the epigastric artery would have run the greatest risk.
Two other kinds of incision have been proposed by Else and A. Cooper for
crural hernia. I have already said something of them in treating of hernia in
general, and inguinal hernia in particular. In the first, the surgeon cuts the
aponeurosis of the external oblique above, and in the direction of Poupart's
ligament, removes the cord by pushing it inwards and upwards, penetrates as
far as the peritoneum, passes a sound bent into a hook between the neck of
the sac and the ring from behind forwards, or from the interior towards the
exterior, and then cuts without fear and as freely as he desires. In the second
also, the aponeurosis is to be cut and the cord removed, but the incision is
made from the exterior towards the interior, although without opening the
sac. These two processes which have been several times tested in the Lon-
don hospitals,, have too many disadvantages to be generally adopted, or for
me to stop to describe or oppose them at greater length.
79
6£6 NEW ELEMENTS OF
ARTICLE III,
Umbilical Hernia.
§ 1 . — Anatomical Remarks,
With respect to hernias the umbilicus is presented in two very different
conditions at different periods of life. Before birth it is a ring with but little
resistance, giving passage at the same time to the three umbilical vessels and the
prolcfngation of the bladder, called the urachus. As soon as the child is
separated from its mother, the parts contained in this ring contract, solidify,
and cease to fill it exactly ; and it is thus that the intestines tend continually
to escape during the first months of life. Later, the ring itself contracts, closes,
is applied against the fibrous muscles formed by the relics of the vessels, so
that in the end the whole presents under the aspect of a very dense inodular
cicatrix ; and in adults umbilical hernias are not made through the ring itself,
as in infancy, but by penetrating the aponeurotic fibres some lines without
its circumference. Seen from the interior of the abdomen, the umbilical
region considered in man entirely developed, sometimes presents a prominence,
and more frequently a slight tunnel -formed depression, upon which are spread
in a radiated manner the suspensory ligament of the liver above, and the
remains of the umbilical arteries with the urachus below. These four cords
circumscribe their four triangles, whose points meet on the circumference
of the mesogastric cicatrix. In the interval, the serous membrane, always
easily recognized becomes more and more adherent as it approaches the centre,
so that behind the ring it is entirely blended with the tissues which it lines.
T\\Q fascia propria or the sub-peritoneal cellular tissue is for the sanle reason
in very small quantity and very compact. The fascia transversalis does not
extend so far. The fascia superfcialis and the adipose cellular tissue, as well
as the integuments themselves, have nothing in them remarkable, except that
they reach like the corresponding tissues behind as far as the umbilical
tubercle, with which they are also very intimately blended. With this arrange-
ment, it is evident that the several points of the umbilical periphery do not
offer the same resistance or the same solidity. On account of the vein being
the last obliterated, of its being naturally softer and less voluminous, and
nothing tending to draw it upwards, the umbilicus in general remains weaker,
thinner, and more easily dilated or passed through in its superior half than
inferiorly, where the three branches, arterial and vesical, are applied with force
against each other, soon -acquiring a solidity which closes it exactly in this
direction. But when it is said that umbilical hernia in adults does not take
place through the ring, some explanation, is necessary. If the term exom-
phalos is reserved for that only which distends and pushes before it the cica-
trix, making it in some measure disappear, it is true that it is only met with in
infants, because in fact it is only possible while the several branches of the
omphalo -placental cord have not yet become solid and transformed into a
fibrous knot. But if it be umbilical hernia whenever an organ has escaped
by the ring which was filled by the expanded vessels during the festal life,j
undoubtedly it is possible, and has been met with at every period of life. M
OPERATIVE SURGERY. 627
in this case the cicatrix is usually thrown to either side of the tumor and
scarcely ever upon its centre, this arises from its being always a little less
adherent on certain points of its circumference than on the rest. Scarpa
relates however, that in one of his patients the sac was divided into several
apartments, by the ligaments of the niesogastric muscles. Moreover, as in this
place there is no circle nor canal naturally open, if is easy to see that hernia
should be made almost as frequently through a fissure of the aponeurosis or
linea alba as through the umbilicus itself; so that Monteggia, who was one of
the first to say that hernias of this region happen without the ring, was only
wrong in making that a constant occurrence which was merely a very frequent
one. Be this as it may, the viscera in this place only pass through a simple
ring. There is no umbilical canal, and it is almost unexampled for the arteries
to have preserved their cavity until adult life. Haller, Boerhaave, and
some others, contended that this is not the case with the vein, the permea-
bility of which however is so rare that it should cause no apprehension in
the operation. In the anomaly observed by M. Manec, the supernumerary
epigastric vein issued through the umbilicus without losing its volume, and
formed an irregular loop beneath the integuments, re-entered the abdomen
through the same opening, and run into the horizontal fissure of the liver ;
while that published by M. Meniere ran directly beneath the liver without
deviating towards the skin. It is evident therefore tliat the risk of cutting this
vein is the greater as nothing can indicate beforehand in what direction it will
be found. As the viscera escapes through a simple circular opening and not
through a canal, umbilical hernia has not, as inguinal or crural hernia, any
sheath, fibrous or serous, which may strangulate it at a variable distance from
its root. The peritoneal layer which is there observed presents, not at all,
or very incompletely, the characters by which it is known in the groin ; and
to exomphalos is strictly applicable what I have said of the absence of the sac
when treating of the operation in general. It was this which Lassus said
was deprived of it in a case in which it was surrounded with such thin cover-
ings, that he opened the intestine which had passed through a rupture of the
epiploon. The external face of the membrane is so closely united with the
surrounding laminae, that it is most frequently impossible to separate it from
them. In reality, it is only the portion which originally line that point of the
ring, which the organs have pushed before them in forming the hernia. Being
enlarged by simple distention, as a cell of lamellated tissue which enlarges
to form a cyst, and not by the progression or accompaniment of the abdominal
peritoneum, it cannot, as in the groin, be distinguished from the other tissues.
A peculiarity no less important in practice is, that it seldom contains any
serosity, and therefore is almost constantly found in immediate contact with
the viscera. I must say however that this law has been laid down in too absolute
a manner. In a woman upon whom I operated some days since for a strangu-
lated exomphalos, there was more than six ounces of reddish serosity in the
hernial envelopes, and about three ounces came from another who was operated
upon at Tours in 1818 by M. Piplet in my presence.
The organs which may be displaced to form umbilical hernia, in their order
of frequency are the epiploon, the transverse colon, the small intestine, the
stomach, the coecum, the sigmoid flexure of the colon, the liver, the duodenum,
and even the pancreas. These several parts are sometimes found in it in so
628 NEW ELEMENTS OF
great a number, and forming so considerable a mass, their containing pouch
becomes extremely thin, so as even to burst at last, as occurred to the patient
mentioned by M. Boyer, whose death the operation could not prevent. More
than once it has been seen, in the foetus especially, entirely deprived of cover-
ing, or only covered with an exceeding thin membrane. Mery and Balzac
have given cases of this kind. I observed one myself in 1819 at Tours in the
practice of M. Mignot. It often happens, but not always, as some facts first
induced me to believe, that the digestive tube is situated, at the beginning of
embryo existence, in the root of the umbilical cord. But if the return of the
intestines does not take place, or only partially occurs before the end of preg-
nancy, the child is born with exomphalos. The viscera in this case should be
covered only by the thin tunics of the omphalo -placental cord. And we
easily conceive how distension may rupture this feeble barrier, and leave the
hernia completely bare. The same may also happen in the first hours or days
after birth. In this respect therefore an essential difference is to be established
between umbilical hernia of the fostus, that of the first moments of external
life, and that of adult age. In the first, the natural tunics of tlie cord form the
sac and the envelopes ; in the second, the cicatrix having had time to be
formed, the organs in issuing must cover themselves with the peritoneum, the
integuments, and the intermediate cellular tissue; the third, obliged to pass
between the vessels or along side of the common knot that unites them, is
moreover forced in the majority of cases to break through the interior of the
ring or the environs of its circumference, to open itself a passage and become
situate beneath tlie skin, distending by degrees the corresponding peritoneum
Frequently too the hernia is aftected at some distance from the umbilicus or
in its periphery. As long as it ia only one or two lines from that point, its
texture and the relative disposition of its elements offer nothing peculiar;
but if it is further removed, the sac and its cellular lining present other cha-
racteristics. The peritoneum is then more movable and less adherent, and
allov.s itself to be carried along and displaced without difficulty; and an um-
bilical hernia of this description is often found furnished, with an evident sac.
The fascia propriay having recovered a part of its laxity > and its thickness,
allows the sac to be distinguished from the external tissues, and fat or serosity
sometimes to accumulate in its parenchyma; and thus have fatty tumors or
hernias been seen to manifest themselves around the umbilicus. M. Fardeau
cites one which was prolonged into the interspace of the two laminae of the
suspensory ligament of the liver. M. Bigot, M OUivier of Anglers, Beclard.
and before them Heister, Petsch, Morgagni, Klinkosch, Pelletan, Scarpa,
Mr. Lawrence, M. Crueilhier, and M. Berard, have met with others which
had their root in the sub-peritoneal layer, and I recently dissected one which
extended as far as the falsiform curve of the umbilical vein. It was probably
above this cicatrix, and not through its interior, that the hernia mentioned by
M. Cloquet escaped, which had pushed before it the hepatic ligament and
used it as a sac.
§ 2, Operation,
The operation for umbilical hernials considered very dangerous, and appears
in fact to be more so than that for inguinal or crural hernia. This depends
OPERATIVE SURGERY. 629
perhaps onihe proximity of the stomach or diaphragm on the organs contained
in the tumor having more immediate relations with the principal viscus of
digestion, or perhaps on the too advanced stage of the disease, when the operation
is usually decided upon. But before looking for tJie causes, it would be better
to establish tlie fact itself, and be positively assured that the operation is
actually more dangerous at the umbilicus than elsewhere. If the tumor is of mid-
dling size, a simple incision parallel with the linea alba, is sufficient to lay it
bare. In the contrary case, Scarpa to the contrary notvvithstanding, there is
no objection to the T incision, or even the crucial. This incision is to extend
at both extremities a little beyond the tumor. In this place the integuments
are in general too tense to allow of the precaution of a fold before dividing
tliem. They are then cut from without inwards as if for laying bare an artery.
The subjacent layers are to be cut in the same manner ; that is, passing the bis-
toury over them with all possible lightness. The sac not being separable is
hard to be discovered, if we persist in cutting layer by layer with strokes on a
determined point the parts which separate it from the skin. But as it is often
very near the cutaneous envelope, and usually contains but very little serosity,
too much caution cannot be used in seeking it. From the moment the bottom
of tlie incision seems to be formed but by a very thin lamella, the instrument
must be handled more lightly than before ; and when the membrane just
divided is found to be separated from the parts it covers by the least interspace,
a director is to be carried beneath it, for we have probably arrived at the sac.
There will be no further doubt on the subject, if any fluid escapes, or if, as is
frequently observed, some fatty lumps protrude through the opening. Having
arrived within the hernial pouch, the bistoury conducted by the under finger,
if the probe pointed bistoury is used, otherwise by the grooved director, imme-
diately enlarges the first orifice and opens largely all the coverings of the
tumor. In umbilical hernia, particularly, the epiploon is apt to be found
forming there sometimes a considerable mass. We must not however be
deceived by appearances. Beneath it is almost always found a portion of
intestine, which it covers, forming in some degree a second sac. For this
reason has been seen here more frequently than elsewhere the intestinal pro-
cidentia rupturing its epiploic covering, passing through it, becoming stran-
gulated in the ring thus made, and placing itself in immediate contact with the
real sac, presenting in a word under the edge of the bistoury the moment that
has penetrated into the interior of the hernia.
After opening tlie sac, the first thing to be done is to ascertain the arrange-
ment of the displaced organs. Consequently some point of the epiploon
which is not adherent is sought with the finger, lifted up, unfolded, and
extended on one edge of the wound. The intestine is then seen beneath,
if it be in the tumor at all. In cases where this simple derangement of the
parts will suffice to allow its reduction, this should be effected immediately.
Hey, and almost every operator since him, have insisted strongly on the
reduction being commenced with the intestine, and not with the epiploon as
recommended by Pott. The intestinal portion having come out last, being
situated more deeply, and in general easier pushed back, is most conveniently
reduced first. However, if an opposite disposition is met with, and the
omentum has more tendency to return than the intestine, I do not see why
we should persist in following the rule laid down by Hey. When the intes-
630 NEW ELEMENTS OF
)
tine is gangerous, and this should rarely be the case, since, as is well knowR
mortification is infinitely slower in manifesting itself in hernias of the large
intestine in entero-epiploceles, and especially in hernias purely epiploic than
in enterocele, it must be recollected tliat stercoral fistulas or preternatural
ani at the umbilicus are seldom cured. This arises, as Scarpa has clearly
established, from there being no membranous funnel formed at the expense
of the sac behind the umbilical circle. How could it be formed in fact, since
the serous surface of the pouch is intimately adherent to it, is formed there,
developed at once, and not borrowed from the internal peritoneum as in
inguinal or crural hernia? Gangrene, or a perforation of the intestine, seems
therefore to require that invagination or the suture be resorted to immediately,
and that we should not attempt the establishment of an abnormal anus. I
would say, however, that in the operation performed by M. Pipelet, which I
have mentioned above, a gangrenous eschar of the intestine was removed, and
a fistula established, which being left to itself ultimately closed and cica-
trized completely. It was also in a case of umbilical hernia that M. Chemery
Have performed invagination with success, and the singular operation
reported by Scarpa, who took it from the old Journal de Medicine.
The incision, when necessary, is so easily performed and attended with sa
little danger that it is seldom dispensed with. It may be done on almost any
point indifferently. Strictly speaking, it may be possible to touch the liver,
to wound the umbilical vein or arteries, and even the urachus ; but to hap-
pen it must almost be done on purpose, unless in case of anomalies which are
too rare to be reckoned among the dangers. We must not, however, forget
the abnormal veins described by MM. Manec and Meniere. Although it is
not sensibly more advantageous to incise the umbilical ring downwards than
in any other direction, I see no inconvenience in following the advice of
authors who recommend for greater safety to direct it upwards and to the
left. By incising largely, the risk of weakening too much the parietes of the
abdomen, and exposing the patient to an almost certain relapse, will be easily
avoided it seems to me, if, instead of making a single incision of half an inch
in depth, three or four are made of one or two lines only on different points,
as in the patient upon whom I operated with M. Gresely ;. if, in a word, the
'• debridement multiple" be adopted in umbilical hernia as in those which
have been treated of heretofore. Although there is no such thing in exom-
phalos as strangulation by the neck of the sac, and although the ring producing
the stricture is generally round, prudence does not the less dictate to see^
before proceeding to the reduction, in what condition is the strangulated por-
tion of intestine. If we operate without laying bare the whole of the tumor,
after the method of Franco, Rousset, or Pigray, it must be recollected that the
ring is seldom distinct from the sac, and unless we combine as directed by
M. Raphel, the process of Bell with this method, we shall not succeed in
removing the strangulation without at the same time penetrating the interior
of the 5ac. This mode of acting is still less proper for the umbilicus titan
elsewhere, although Scarpa recommends it with a kind of complaisance, and
Sir A. Cooper had recourse to it twice with success in similar cases. Imme-
diate union may be attempted with more advantage and facility after umbilical
celotomy than in the after treatment of hernias of the groin. The whole
pouch, formed in some measure of a single layer, has a much less tendency
OPERATIVE SURGERY. 631
to roll Upon itself, and a much greater to reapply itself to the points it origi-
nally occupied. I cannot advise it, however, because in my opinion the
operation renders the radical cure so much the more probable as the wound is
cicatrized in a manner more completely mediate. For the rest, this is the
part of the body where the organs have the most need of being sustained by
moderate compression, after being returned into the abdomen, and this, no
doubt, because the opening which afforded them passage, is usually very
large, and because especially it forms a ring, a complete circle, which passes
directly through the abdominal wall.
Art, 4. — Ventral Hernias,
Hernias in the linea alba, whether above or below the umbilicus, differ too
little from those we have just examined to require a special description. If
they happen to become strangulated, which is almost unheard of, their opera-
tion will have nothing in it peculiar. The same must be said of the hernia of
the flank or loin, described by J. L. Petit, observed once at Mont Rouge by
MM. Cloquet and Cayol in a man seventy-five years old, on another occasion
by Lassus in a subject who had one on each side ; since then by Pelletan in a
woman who had the belly simultaneously studded with hernial protrusions.
Ventral hernias, properly so called, that is, those which are formed without
the linea alba, umbilicus, and other natural openings in the abdomen, either
from a simple fissure in the aponeurosis or muscles, or in consequence of a
cicatrized wound of the parts, as Schmucker, Desault, Lassus, Richerand,
Anderson, and a host of others have observed, are scarcely ever strangulated ;
or if strangulation does take place it is almost constantly possible to reduce
them by the taxis, by position, and other resources pointed out in the preced-
ing articles. It is seen nevertheless in the English journals of late years that
neither Mr. Key nor Mr. Bransley Cooper could reduce a strangulated ventral
hernia until after subjecting it to an operation and cutting the stricture, when
the patient was happily restored. Supposing all these species of tumors to
require celotomy, we should act as in cases of umbilical hernia, and they will
require no other cure than the course of the epigastric, lumbar, or anterior
iliac may demand.
Obturator hernia, of which examples are given by Arnault, father and son,
Duverney, Garengeot, Verdier, Pipelet, and Eschenbach ; since observed by
A. Cooper, H. Cloquet, Hesselbach, and Marechal, and which seem to be
sometimes susceptible of strangulation, would be a little more embarrassing.
The opening which affords it passage being then transformed into a kind of
canal, the pelvic orifice of which is formed by the pubis outwards and up-
wards, and by the obturator membrane in the rest of its extent, is limited by
the thickness of the obturator muscles. In this case, the viscera are sur-
rounded by the pectineus anteriorly, the adductor magnus posteriorly, and the
adductor brevis and longus interiorly and superiorly. Being obliged to pass
through these several muscles, or to separate them to become evident at the
internal and inferior extremity of the hollow of the groin, obturator hernia
does not appear susceptible of being strangulated but at its entrance into the
obturator canal, as really occurred in the cases of it w^hich have been reported.
It seems that the sub-pubic artery being always found on its external side.
632 OPERATVE SURGERY^
either above, below, or directly ■without, the incision must be made on its
internal semi-circumference. I know that this operation was first attempted
by Garengeot on one of his patients, rue du Sepulcre, and more recently by a
German surgeon in a very similar case ; but when we think of the parts to be
passed through to arrive at the seat of strangulation, of the depth of the obtu-
rator membrane, and of the difficulty of discerning the place occupied by the
vessels, and that the bladder or vagina may be touched, it is quite allowable
not to recommend it. Ischiatic, perineal, vulvary, and vaginal hernias also
enter entirely into the domain of surgical pathology, and have no other rela-
tion with operative surgery than inasmuch as the taxis, position, and retaining
bandages methodically applied, form their principal remedy.
OPERATIVE STRGERY. 63S
CHAPTEH IV.
SEXUAL ORGANS.
The genital system of either sex calls so often for the assistance of opera-
tive surgery, that it alone could furnish the surgeon matter for many volumes.
I must be permitted to say a few vi^ords, in anticipation, upon some of the
least familiar of its diseases.
Vegetations. — In 1825, 1 was conducted by Mme. Delon, a midwife, to the
house of a lady, aged about 30 years, and who for some months preceding
had had a pyriforme tumor, red, and of but little consistency, about the size
of a nut, the lower extremity of which was swelled or rounded and slightly
projecting, attached by its root to the urethra, at a depth of 4 lines. I seized
it with a curved hook, drew it a little towards me, and excised it on the spot
without giving the least pain to the patient, who was well on the next day.
In 1 829 I met with a case precisely similar. By a reference to the Lancet
it will be seen that Mr. Wardrop has noticed three others. Similar vegetations
have been mentioned as occurring in females by Vogel, Rosenmuller, Chaus-
sier ; and every thing leads to the belief that excision is the true remedy for
this affection.
It appears that men are equally liable to them. I know of two instances.
In one, the excrescences, three in number, scarce equalled in size the bulk of
a grain of barley. In the case of the second patient, a young Englishman, who
w^as pointed out to me by Mr. Beaumont, a student of medicine, there were
likewise several, but they were still smaller. They were similarly inserted
behind the meatus urinarius. None of them reappeared after being injured or
excised. Are not the polypi of the urethra, about which M. Nicod has for
several years entertained the public, and about which he has again published
an essay, of this genus of production ?
SECTION I.
Sexual organs of the Male.
»^rt, l.—The Scrotum,
§ 1. Anatomical Observations,
As I remarked when speaking of inguinal hernia, it is almost always easy,
with a little attention, to distinguish six or seven concentric tunics, or coat3
in the scrotum; 1st, the skin; 2d, the subcutaneous layer, which covers at
once the two testicles; 3d, the deep lamella of the cellular layer, which,
enveloping the whole extent of the cord and of the testicle, come together to
constitute the dartos and the septum, in such a manner as to separate the t,wo
seminal glands from each other. Beneath these three first layers, which may
80
634 NEW ELEMENTS OP
be called the general, we have presented to us the mferior or special sheaths, Isf,
that which is continuous with the circumference of the abdominal ring ; 2d,
the cremaster muscle, which immediately after it envelopes the testicle
completely, and goes down to the bottom of the scrotum of the corresponding
side ; 3d, the fascia transversalis, which constitutes what is properly called
the sheath of the cord, which sheath contains within it the fascia propria, the
cellular tissue, and the spermatic nerves and vessel, with the vas deferens,
and which ceases at the adherent margin of the seminal gland. We have
already seen that but few vessels are distributed to these numerous layers ;
they are, externally, the same branches of the scrotal or external pudic
arteries, placed transversely or obliquely between the cremaster muscle and
fascia transversalis ; — the inguinal branch given off by the epigastric and
the spermatic artery enclosed in the sheath of the ring. In the centre of all
these coats, there exists yet another called elytroid or vaginal, which sepa-
rates them from the testicle. It is a small sac adherent on its external
surface, soft, smooth, bedewed with serosity without, and which may be
divided in the mind into two portions, as the pleura is ; the one portion pari-
etal, spreading over the inner surface of the external coverings, the
other portion visceral, which invests the testis as far as its adherent
margin, at which the two sides of this layer form by their approximation a
septum, before they spread out to become continuous with the parietal layer.
Superiorly the elytroid tunic is prolonged into the inguinal canal, crossing it
to become blended with the peritoneum, of which it is but an appendage.
In fact, previous to birth there is no serous coat in the scrotum, which at
that period is composed in reality only of integuments and subcutaneous
layer or fascia superficialis. It is indispensable that he who would form an
accurate idea of what is observed in later years should recollect this dispo-
sition of parts. The testicle, which during foetal existence was hidden
underneath the kidney, or below the Fallopian ligament, drags with it the
peritoneal coat by which it was covered in the abdomen, and to which it
adhered intimately only at its posterior margin, and when it makes its
appearance externally turns it over upon itself. As it continues its descent,
the testicle carries before it both the fascia transversalis, the small oblique
muscle, and the fibro cellular divi^ion of the obliquus externus. These ail
press upon the three primitive tunics of the scrotum ; but, inasmuch as the
deeper of these three latter had previously contracted adhesions to the
inferior surface of the penis, a septum consequently results which is soon
much increased in thickness by. the correspondent sides of the distinct
pouches whj^h have descended from the abdomen. The portion of peritoneal
prolongation, which is contained in the inguinal canal, and which embraced
the side of the'cord in its upper portion, confined within a contracted space,
and having no longer any functions to perform, is speedily closed and obliter-
ated, and even so blended with the surrounded tissues, as that in adult age
no other vestiges of it are discoverable save the funnel-shaped depression
observed at the visceral opening of the track of the testicle, so that the
exterior serous pouch is then completed, occluded, or made to terminate in a cul-
de-sac both above and below. Certain writers have been of Hunter's opinion,
and it is one which even at this day is pretty generally acceded to, that the
exterior layer, now known as the fascia superficialis enters the belly through
OPERATIVE SURGERY. 635
the inguinal ring to be attached to the adherent margin of the testicle : that the
prolongation, called gubernaculum testis by the English surgeons, forms by
its extension the dartos and the septum ; in a word, that its function is to draw
down the glands to the bottom of the scrotum. M. Blandin lias thought that
he perceived, in the natural enlargement of the parietes of the abdomen after
birth, the explanation of the descent of the seminal glands, and of the imagi-
nary expansion of the gubernaculum testis. But M.Manec has noticed, and
I verify his observation by my own, in the case of an adult whose testis was
still within the abdomen, that the fascia superficialis passes before the abdomi-
nal ring, in the external oblique muscle, and does not penetrate into it. I may
add, that this ring is then separated from the external tissues, by the very
external layers which are to be extended at a later period around the cord,
to form its fibrous tunic, and that the idea of Hunter seems to me wholly
without foundation.
§ 2. Hydrocele.
It frequently happens that serum accumulates or spreads between the
different layers of the scrotum. If it be betwixt the integuments and cellular
tissue, or between the cellular tissue and the prolonged aponeurosis of the
external oblique, the hydrocele will evidently be diffuse — will rarely remain
limited to one pouch of the scrotum only. If on the contrary the fluid
passes between the fibrous tunic and the cremaster, or between the cremaster,
the fascia transversalis, or even the fascia propria, the hydrocele, although owing
to infiltration, may nevertheless be arrested at one of the halves of the scro-
tum. It is doubtless owing to their puncturing to this depth, that young men,
who with the hope of avoiding military service, endeavor to simulate inguinal
hernia by inflating the testicular tunics with air, succeed occasionally in
deceiving professional persons. If the infiltration occurs in the tissue of the
cordi that is to say between the lamellae which connect its vessels and its
excretory duct, we may still have a diffused hydrocele, but one which is
limited by the thickness of the cord without entering the scrotum. When,
instead of its being disseminated in a number of distinct meshes, the serum
is deposited in one or several particular sacs, that form of the aff*ection results
which is called hydrocele from effusion. Whenever the effusion is carried
on in one or other of the places just indicated, viz : between the tunics of the
scrotum or in the thickness of the cord, it takes the name of encysted hydro-
cele. This latter species is most often seen around the spermatic vessels and
duct, for the simple reason that the areolar tissue is here particularly encoun-
tered. The name of encysted hydroceles, which has been given by many to
those serous accumulations which are seen to occur in the thickness of the
epididymis of the testis itself, or between that fibrous tunic called the
alhiiginea and the serous layer which covers it, might perhaps in strictness be
retained with propriety. But as these are real diseases of the prolific organ,
more than one inconvenience would result from their conjunction with hydro-
cele properly so called.
The vaginal tunic, being the only one naturally free, and exhaling continu-
ally an aqueous vapor, is that which is most often the seat of the effusion in
question ; so much so, indeed, that the word hydrocele, unaccompanied by
636 NEW ELEMENTS OF
anj other epithet, is employed only to designate this particular variety. The
parts composing the scrotum in which a hydrocele of the tunica vaginalis
has for a long time existed undergo at times numerous changes. Dr. Mott
has met with a scrotum in which an envelope existed, formed almost entirely
of small calculi or stony projections. An osseous degeneration of the
same tissue, has been recorded by Wagner, Beclard, M. Cloquet and M.
Yvan ; at other times the degeneration observed resembles cartilage, or is of
a lardaceous nature, which may increase in hardness and thickness, and form
at length a truly hard and tough shell. The internal surface has been found
villpus, knobbed, tuberculous, or covered with fungous growths. The liquid
enclosed in these cases is far from being always limpid or of a lemon color.
It is in certain cases reddish, or deep brown more or less dark, resembling
chocolate ; again it is of a decided yellow, and much more thick in consistence
than is usual. Beclard and M. Cloquet have remarked in it small crystals of
a micaceous, greasy, or chalky material. MM. Murat and Baillie have noticed
therein, small, smooth, floating cartilages, and it is even said real calculi ;
sometimes, also, a viscous, stringy substance, whose presence was generally
coincident with extensive disorganization of the lining membrane. The serous
expansion of the scrotum may ofter or encounter more resistance in one way
than in anotlier. In this case it happens sometimes that its dilatation is
unequal ; so that the tumor carries the testicle before it, even to its external
surface, spreading out the cord, either as Scarpa thinks by effecting its decom-
position, or in giving it a riband-like appearance, instead of leaving it within
which is asserted by M. Dupuytren. It is owing; to this unequal dilatation,
that a hydrocele often presents inequalities on the exterior, or is divided into
two or more portions, having the form of a double bag.
It is to be observed, however, that to separations in the fascia propria, or the
cellulo -fibrous tissue which immediately surrounds the tunica vaginalis,
similar protuberances are owing.
Operation. — Hydrocele from infiltration requires no instrumental aid, unless
it be decided, after a fruitless exhibition of appropriate topical applications,
to treat it by slight punctures or scarifications, or by two deep incisions
made on either side of the median line on its inferior surface, which are still
advised by Sabatier, and which formerly were in such high estimation.
In a hydrocele from effusion, whether one in which the fluid occupies the
tunica vaginalis, or be contained in several cysts, it appears to be now gene-
rally admitted that the patient is never relieved either by local topical,
applications, or general treatment. It would be incorrect, however, to receive
this assertion in too unlimited an extent. It is certain, on the contrary, that
hydrocele of the tunica vaginalis itself even has disappeared under the
agency of certain cataplasms, lotions, and other topical measures. The the-
sis of M. Lesuer, for instance, shows that in the Hotel Dieu of Paris, leeches
and revulsives have triumphed frequently over the disease. By the work of
M. Sabatier, again, it will be seen that M. Dupuytren lias cured many by
means of blistering the tumor, and M. Manoury and many other practi-
tioners have cited numerous facts in support of the practice. On the
authority of M. Bertrand, moxa in the hands of others has not been less
efficacious. M. Grsefe of Berlin has recently revived the boasted prescrip-
tipn of Keate in 1788, consisting of a solution of the mur. ammon. in alcohol
OPERATIVE SURGERY. 63T
or the acetate of squills. I have myself twice seen a hydrocele removed by
the use of such astringent cataplasms as are advised by M. Brodie, and by
frictions with the mercurial ointment; but these exceptionable instances
of success are very rare, and met with only in long standing cases, in which,
the hydrocele was small, or could be traced either to a traumatic lesion or to
an irritation whose principle it was possible to discover. In the two cases
which I saw eft'ected the disease was but of two months existence, and origi-
nated in a blenorrhagic swelling of the testicle. Latterly, blisters, the
muriate of ammonia in aqueous solution, afterwards red wine, and the most
powerful astringents were vainly employed in two of my patients, in whom
nevertheless the hydrocele had existed but six weeks, and was owing to a
bruise of the testicle; leeches and emollients had been previously applied,
but with a similar want of success; the operation, however, was very readily
triumphant. Spontaneous cures are occasionally met with in hydrocele.
Bertrand and Sabatier have seen it following vioknt straining in coughing
or micturition. Loder speaks of a patient in whom the kick of a horse had a
similar result. The tunica vaginalis is ruptured, infiltration of the scrotum
and penis follows, the effused fluid is speedily absorbed, and the hydrocele
disappears finally, or for a few months only, as in the case recorded by M,
Boyer. Two new occurrences of this nature have been published in La
Lancette by M. Serre of Montpelier. A third is contained in an essay by
M. Bertrand. I have also learned from M. Double, a house pupil, that in
a patient under the care of M. Roux, at la Charite, no vestige whatever of
the disease remained on the day on which it was to have been operated
upon. Notwithstanding all this, the operation when preferred is so simple,
and its effect so uniform, that, even supposing we could by the aid of topical
applications succeed in curing a certain number of cases of hydrocele, it
would still deserve to be uniformly put in practice. The steps in its per-
formance have singularly varied since the days of Celsus.
Incisions into the tumor, the excision of a portion of the sac, scarifications
on its internal surface, cauterization by the red hot iron, or caustics, the use
of tents, pledgets of lint, canulas, setons, and of various injections, all have
been so highly lauded, as to constitute numerous plans of practice, the greater
part of which modern surgery has now discarded.
Cauterization, as described by iEtius after Leonides, was in use very long
before the time of Guy de Chauliac, to whom Sabatier seems disposed to
award its employment. By some it was effected by establishing an eschar
on the inferior part, by others on the superior part of the tumor, which eschar
was renewed until it reached the fluid. Certain other operators preferred to
effect the object by means of heated metal, or by that L shaped cautery
spoken of by Paulus ^ginetus. The practice, which has a thousand times
been revived, has been particularly commended by Else in England, Du-
saussoy in France, and by Eilrich in Germany. The second of these writers
imagines that the effect of the escharotic is not merely to produce sphacelus
of the scrotal tunics, but that it induces simultaneously a gangrenous inflam-
mation of the whole tunica vaginalis, which is seen to fall away in flakes
after the separation of the eschar. Humpage had conceived a method of
creating it by placing some of the spirit of salt (an aqueous solution of hydro-
chloric acid) around a circular plaster, which was to serve as a protection to
€38 NEW ELEMENTS OF
the tissues in the vicinity of the cauterized circle. Be this as it may, it is, under
whatever form it be executed, a treatment which ought to be definitively pro-
scribed.
I should think quite as unfavorably of the tents of the canulas, which are
much less dangerous and barbarous, were it, not that some highly distin-
guished practitioners of our day continue to advocate their employment. The
use of these measures, so far from being original with Franco, Fabricius ab
Aquapendente, or with Moimiches, as Sabatier and M. Boyer would lead us
to suppose, goes back, in fact, at least to the time of G. de Salicet, who in
speaking of hydrocele makes use of these words : '' Let the scrotum be
punctured with a lancet, and the water drawn off, and then let a tent be placed
in the aperture, so that when you will you may freely draw oft' that which is
within the enlargement."
Instead of a proceeding so simply, F. de Hildus has proposed to place a
ligature round the tunica vaginalis, incise it and to leave there a pledget of
lint ; which proceeding Bell has copied under this latter point of view.
Monro recommended that the serous tunic of the testicle should be irritated
with the- point of a trocar; Larrey, that one of gumelastic should be allowed
to remain within it for several days. If it be incontestibly true that the use
of these measures is attended with a certain ratio of success, it is not the less
true that suppuration in, and not simple adhesion between the surfaces often
results from them ; and that they are not so constantly successful as to bear
any comparison with the methods at present resorted to. The same is to be
said of^setons, about which M. Sabatier has found no mention made by the
ancients, which Sprengel refers to Lanfranc, and M. Cooper attributes to
Franco, although it was in all probability alluded to by Galen, when he says
that we must draw off the water from the scrotum either with a syringe or by
means of a seaton.
It is, besides, at the instance of the phycisian of Pergamus, that Guy de
Chauliac advises us to seize the scrotum with flat forceps, having an opening
at their extremity, so as to permit the passage through them of a long heated
needle, to the eye of which is attached the seton which is to be left in the
wounds until the water is evacuated. It would appear moreover, as lias beeu
remarked by Le Clerc, that C. Aurelianus had intended to indicate it. Pey-
rilhe also thought that he discovered in the works of Paulus ^gineta a refe-
rence to tlie same idea. Notwithstanding this method received, until towards
the end of the seventeenth century, the commendation of all authors, it was
nearly wholly abandoned when Pott, sixty years ago, undertook to re-establish
it. The method of proceeding which he adopted, and which has since
been modified by Roe of Edinburgh, needs not here to be brought for-
ward, and the less so that it is not probable that setons will henceforth be
employed by any one. Should it however be thought fit to return to its
use, its name alone serves to explain it; and it needs but to be remembered
that a long pledget of cotton, or any other material, or a thin riband, is to be
passed through the swelling, that all may understand the mode of conducting
a similar operation. There now remains for comment, incision, excision, and
injections.
ist. Of Incision, — This operation, which since the time of Celsus, of Paulus
^ginetus, of the Arabians, of Guy de Chauliac, has been practised in every
OPERATIVE SURGERY. 639
age, Is performed with a strait or convex bistoury. The patient is placed on hi&
back, and his limbs moderately flexed. The surgeon grasps the posterior
surface of the scrotum with his left hand, and thus make& tense the tumor.
With the right hand he makes an incision on its interior face in tlie upper part
from without inwards, if the convex bistoury be employed; andbypuncturing,
if he makes use of the straight bladed instrument, The opening ought to be
large enough to admit the finger, or if by accident the incision be too small to
permit this, a director must take its place. A button, or probe-pointed bis-
toury serves to complete the division of all the anterior portion of the cyst, pro-
ceeding with the incision from within outwards, and from above downwards.
As the object is to produce adhesion between the two layers of the tunica vagi-
nalis by exciting suppurative inflammation, the wound is to be filled with lint
and dressed daily, that it may fill up only from below towards the edges. By
these means a very permanent cure is generally effected; only it sometimes
happens that small spots in the membrane escape the irritation, and by giving
rise afterwards to small cysts, permit a partial reproduction of the disease.
In France at least, since we possess methods so much more simple, the pain and
risk which attend it sometimes, and the length of the treatment, have caused it
to be generally rejected ; so that, notwithstanding the reasoning of M. Rust
and M. Gama, who still give it the preference, it seems proper to consider it
only as an occasional resource : as, for example, in case of encysted hydrocele,
of multilocular hydrocele, and of hydrocele complicated with extensive lesion of
the tunica vaginalis or of the testicle itself.
2d. Excision. — It would appear that excision also has been practised since
the time of Leonides. We read in ancient authors, and in Paulus ^ginetus
amongst others, that after having laid open the tumor, some of them were in
the habit of seizing the lips of the tunica vaginalis, and rolling it within upon
hooks in order to tear it away. It is to Douglas, however, that the merit of
directing to this method the attention of surgeons in the last century, and the
important rank which it still holds amongst us, is due. Imbert de Lonny, by
combining it with the use of tents, thought that he had instituted a new practice,
which has not been adopted. It may be done in various ways. It was the practice
of the English surgeon, to begin by circumscribing within two semilunar inci-
sions, an elliptical portion of the integuments on the fore part of the scrotum.
This portion he removed, opened into the tunica vaginalis, which he afterwards
gradually dissected until near the adhesions to the testicle, so as immediately
to excise both sides by the assistance of good scissors. M. Boyer advises a
simple incision the whole length of the hydrocele, then that we should dissect
the tunica vaginalis as far away as possible from the side of the seminal
gland before we give exit to the liquid within, and then to open the cyst and
cut away a portion. Lastly, it has been found more simple by M. Dupuytren,
to grasp the whole tumor below with the left hand, so as to project the anterior
wall as much as possible, to make the incision either on the plan of Douglas or
Boyer, as it appeared to him adviseable or not to remove a portion of the inte-
guments ; then to isolate as it were the tunica vaginalis by pressing it from
behind forewards treating it, in a word, almost as one drives a kernel from its
fruit by pressure with the fingers. This done he opens into the cyst and ex-
cises it as we have before mentioned. The wound is immediately filled with
dry lint after eitlier method of operating, and the dressing is the same as after
640 NEW ELEMENTS OF
simple incision. From this detail, it will be seen tl)at the operation by
excision is a painful one, and necessarily a longer one than the others. It has
the advantage of preventing all return of the disorder, since it irrecoverably
destroys the membrane in which it takes place. Still as it is almost impos-
sible to take away the whole tunic, it does not appear how it should place the
patient irrecoverably beyond the possibility of a relapse. It has been besides
observed, by M. Boyer, that hydrocele returns sometimes after excision as
well as after incision ; and the method, at least as a generally applicable one,
is to be proscribed. It is applicable only in those rare cases in which the
vaginal tunic is hardened, has degenerated into a cartilaginous or fibro carti-
laginous state is studded wilJiin or without with bony or calcareous
spots ; considerably thickened when it forms a hard and solid shell ; or when
for some reason we have grounds for suspecting that the internal sur-
face is not likely to take on adhesive inflammation ; or when lastly, it exists
as a foreign body in the scrotum which it is necessary to remove.
3d. Injection. — Most modern authors, proceeding on the assertion of A.
Monro, attribute to an army surgeon of the same name as that author, the em-
ployment of injections in the radical cure of hydrocele. They had however
been proposed, and the proposal acted upon long before. Celsus tells us that
where the water is in a pouch, we must after evacuating it inject with solutions
of nitre or saltpetre. Lembert of Marseilles, in his commentaries and obser-
vations published in 1677, distinctly says that the best method to be followed
in the cure of hydrocele, consists in evacuating the water through a canula, so
that the cyst may be inflamed by an injection, through the same canula, of the
aqua phagedenica. With so much confidence had his trials inspired him in this
species of medication, that he declares his intention to use no other. The
praises lavished upon this process, first by Monro, then by Sharp and Earle,
having been invalidated by the failures of many other surgeons, it did not take
in England, and indeed has been only of general adoption within thirty years
past in France, As it is now almost the only one practised, I shall dwell upon it
in an especial manner, and give a more detailed account of this than any of
the other methods.
The inutility of the precautions laid down by Benjamin Bell, who instead
of the ordinary one, advises the use of a flat trochar, and recommends that
previous to making the puncture the skin and the teguments subjacent be
divided with a lancet. Being now universally acknowledged, I shall neither
stop to discuss them nor the directions of Scacchi, who has highly vaunted
the excellence of an elastic canula surmounted by a cutting extremity, in as
much as the trochar, commonly called the hydrocele trochar, with or without
teeth on one surface of the sheath, is considered amply sufiicient for all cases.
If however no variations are now made in the best instrument for puncturing
the cyst and withdrawing the fluid, the case is nowise the same as to the irri-
.iiting agent to be employed for the injection. The ancients, as we have seen,
'.ad recourse to solutions of more or less acridity. Lembert employed lime
water containing corrosive sublimate. The surgeon of whom Monro speaks
employed alchohol, either pure or diluted with water. During the same
period red wine was tried. Earle has much recommended port wine weakened
with a decoction of rose leaves, while Juncker, of Berlin, approved of medoc
and water, and many others were content with solutions of the caustic potash,
OPERATIVE SURGERV. 641
MM. Boyer, Richerand, Dupuytren, and Roux, have permanently decided
on the use of red wine, either simple or mixed with a little brandy or alcohol,
in which the leaves of the Provins roses had been boiled. I have seen used
by M. Jules Cloquet, and have myself employed, camphorated alcohol in one
case, and in others brandy, pure or camphorated, to effect tlie same result.
Some physicians at Angers, as it appears, have employed injections of nothing
but cold water. Beclard, has cited some cases v/hich were attended with
success by these means, and M. Cuvellier in his thesis, has related a greater
number still. Jn one case related by Schreger air alone was not less suc-
cessful. It is easy, when we reflect on the object to be accomplished, to
conceive that any of the above methods are in themselves of such a nature
as to bring about the desired end. All that is necessary is to irritate the
tunica vaginalis, and excite in its interior an adhesive inflammation. Now to
produce such a result, cold water, wines of all kind, brandy, caustic solutions,
in short any liquid whatever, as well as the beak of a canula, of a tent, the
presence of a foreign body be it what it may, are evidently proper. The
thing is to know what best succeeds, and creates at the same time the fewest
inconveniences. Experience having decided in favor of red wine enlivened
with a little alcohol in which roses have been boiled, I do not see why we
need go on to make trial of others. I must remark however, that alcohol,
which many have rejected from a belief that it was of two irritating a nature,
and capable of causing dangerous inflammation, produces effects no more
alarming than those of common wine, and that if I do not myself use it,
it is because I have seen it fail of effect three times in eleven cases upon which
I operated; whilst wine, which was used exclusively by M.Gouraud whilst I
was at the hospital of Tours, and which is employed by M. Richerand at the
hospital St. Louis, and at the Hopital de Perfectionnement by MM. Bougon
and Roux, and which I have myself used in about sixty cases of which I have
an account, has failed five times only.
Hie Operation. — Prqyarations. Before the scrotum is evacuated a syringe
must be at hand capable of holding about two pints, and in perfect order.
A quart or two of liquid, placed as has just been said, and a chafing dish of
live coals to heat it, should be likewise ready ; several basins are likewise
necessary, either to contain the wine for the injections or to receive the fluid
of the hydrocele. When all the preparations are thus completed, the patient
is to be placed upon a table protected by cloths, or on the bed, and the
surgeon supports the scrotum, as in the operation of excision or incision ;
assures himself anew that it is really a hydrocele before him, and not
any other disease ; and that the testicle, and the different components of the
cord, are in such and such a state, and in no other. To be certain on this
point, he suddenly raises the scrotum, places the cubital edge of one hand
perpendicularly on its anterior surface, so as to intercept the light of a
candle held on the opposite side, in such a manner as that the rays of light
must pass through the serous cyst to reach his eye. The natural transpa-
rency of the fluid contained within the cyst, then enables him, when perfect,
to detect the precise location of the testicle, and even of the spermatic cord.
If any doubt still remains, it is proper to employ the little instrument invented
by M. Segalas for seeing into the bladder, or a tube of wood or gum-
elastic, a foot in length and several lines in diameter will answer the purpose.
81
642 NEW ELEMENTS OF
The operator then takes the trocar, fitted with its canula, in his right handy
and plunges it at one blow into the centre of the liquid on the anterior,
lower, and exterior surface of the tumor. To this precise spot a preference
should be given, because, in the natural state the testicle and its dependencies
are situated within, below, and behind; and because it is the best mode of
hitting the middle of the tunica vaginalis. It is useless to saj, that if before
commencing the operation we could have been aware of the different distri-
bution of parts, the instrument should have been introduced in another
direction at a more suitable spot. The want of resistance, the. escape often-
times of a drop of the fluid between the canula and the wound and the
depth to which we have arrived, are sufficiently indicative of the trocar having
entered the cyst. The surgeon then takes hold of the tube with the index
and middle fingers of the left hand, near the skin, and on the instant with-
draws the canula sufficiently far to allow the liquid freely to flow out. When
the sac is in some measure empty, he presses upon it in all directions, taking
care that the point of canula follows the retraction of the part, lest it should
become fixed between the other enveloping tunics. Up to this point the beak
of the instrument must not be pressed against the morbid cavity in such a
way as to interfere with the exit of the fluid.
An assistant now fills the instrument with the injection, which is to be at
a temperature of about 32° cent.; more if the tissues in the individual seem indo-
lent, or if the liquid itself be not of a very stimulant nature; a little less
if the circumstances of the case are reverse; so warm, in short, as that the
hand may be able to endure the heat though with slight inconvenience. The
syphon of the syringe is now to be introduced into the external opening in
the canula, to which it ought to have been previously fitted to be sure of its
accurate adaptation. The assistant then slowly pushes down the handle until
the syringe is emptied. The operator, holding the canula at its root, prevents
it from moving within the sac or from withdrawing into the thickness of the
scrotum, whilst as the assistant removes the syringe he applies the index
finger to the orifice, and thus prevents the escape of the liquid. A second and
a third fresh supply of the injections are forthwith similarly introduced, if
necessary to enlarge the tumor to the dimensions it possesses before the opera-
tion. It is retained each time for about two minutes in the tunica vaginalis by
some, by others for five, and there are again others who prefer its continuance
for even six or seven.
There are some who recommend that the tunica vaginalis be filled a third
time before it is finally emptied. It is prudent to press out from it the few
remaining drops of the liquid, and even the air which may have obtained admit-
tance before the canula is withdrawn. It is customary in the after treat-
ment, to surround the scrotun with compresses steeped in the same wine as
that injected, which are to be renev/ed thrice in the twenty-four hours, until the
fifth or sixth day ; that is, until the inflammation has attained the desired acute-
ness, when they may be replaced by emollient poultices. In some individuals
the inflammation is at its height on the morning after the operation; in
others it is not reached before the fourth, fifth, and even the sixth day.
In one patient upon whom I operated in November last, no swelling or pain
supervened during the two following weeks. Symptoms of inflammation
appeared only about the tenth or twelfth day, although the person was young.
OPERATIVE SURGERY. 643
easily excitable, and of a nervous, rather than a lymphatic temperament.
He had suffered the operation on the other side the year before, but with no
greater inconvenience. In both instances the success was complete. When
this happens the tumor is hot, red, painful, and resumes nearly its original size.
A febrile movement, or even a pretty severe attack of fever, with all the
symptoms of evident constitutional reaction accompany the local irritation,
while at other times the system seems wholly insensible to what is passing
within the scrotum.
The matter efifused into the midst of the tunica vaginalis offers this
peculiarity, that it is soft, pasty, or semifluid, and forms, in the strictest sense
of the word, matter or plastic lymph. In a considerable number of cases
there is along with it a certain proportion of serum; but scarcely ever albu-
minous shreds or true pus are secreted.
The eflfusion continues during the advance of the inflammation. Its reabsorp-
tion is effected by degrees, so that in about twenty days, a month, or six weeks,
the parts may be restored to their natural size, affecting apparently the enve-
lopes of the scrotum, which were more or less thickened, and the testicle, the
swelling of which is an almost necessary consequence of the primary disease or
the subsequent operation. Whilst the more fluid parts of the effused matter
are being absorbed, its solidifiable portion becomes organized ; vessels traverse
it, and insensibly it becomes blended with the two sides of the tunica vagi-
nalis. Being ultimately resolved into cellular tissue, it so perfectly unites the
two layers of the serous tegument which had secreted it as to leave behind
no cavities between the testicle and the neighboring layers, which is in fact
saying the result is a total obliteration of the cyst itself. This is the pro-
fessed aim of all surgeons, be the operation to which they resort what it may.
It is this result which one and all have pretended they could attain by extolling
the varied practises of cauterization, incision, the use of pledgets of lint merely,
or lint smeared with medicinal preparations, ligature, excision, the introduction
of tents, ribands, canula of elastic gum or of metal, setons, or any irritating
liquid whatsoever. And from this statement it follows that it is in reality
admissible, since the object is the same, for anyone to modify the treatment of
hydrocele at pleasure, according to his peculiar views or the personal ex-
perience he may have acquired.
From a remark made by Pott it would seem that he did not consider the
disappearance of the vaginal cavity as indispensable. An opinion upon this
subject, has since been formally promulgated in England, which is in oppo-
sition to that of almost every other practitioner of the day.
Mr. Ward has in fact asserted positively that hydrocele is sometimes re-
covered from, even when tlie serous tunic of the scrotum preserves its original
dimensions. Mr. Ramsden is of the same opinion, and if I may judge from an
essay by Mr. Walsh, Mr. Kinderwood, another surgeon, has predicated on
the fact, a new method of operating yet more simple than any of which I have
spoken. His plan is to divide the whole of the tissues down to the tunica vagi-
nalis, of which membrane a small portion is to be dissected off and excised,
and then the liquid having escaped, the edges of the wound are to be reunited
by the aid of a stitch. Although I do not participate in the hopes of Mr.
Walsh and his countrymen on the subject of this operation, I cannot omit to
state a fact recently collected at Pitie, which strongly corroborates the
6*44 NEW ELEMENTS OF
opinion entertained by Pott. The patient of whom I speak was upwards of
fifty years old. His hydrocele was of the size of the two fists; I operated
upon him by the vinous injection. On the twenty-sixth day after the opera-
tion, when the scrotum had regained nearly its natural size, the man fell a
victim to an apoplectic attack. Curious to investigate the pathological phe-
nomena, I dissected the parts with great care, and was astonished to find
the elytroid tunic entire, its polish natural, and containing nothing save at the
lower part a slightly greenish mass of filamentous and gelatinous texture,
which had no adhesion whatever to the inner surface of the serous membrane.
The testes and general teguments of the scrotum, were in all other respects
perfectly healthy.
When the inflammation begins to abate, which it does toward the eighth or
tenth day, poultices are generally useless, and compresses moistened either
with wine or the aqua vegeto mineralis, ought to be substituted for them.
As the resolution of the swelling is sometimes accomplished with extreme
slowness, it is proper to hasten it by suitable measures. Poultices of flax seed
moistened with the extraction saturni, I have often seen successful. Upon the
whole, those remedies which have seemed to me the most eff*ectual have been
mercurial ointment, and unguents made with the iodites and hydriodates,
alone or combined with opium, rubbed in small quantities on the testicles.
A very important precaution throughout the whole course of treatment is to
keep the testes securely supported by a suspensary bandage nicely adjusted.
Although it is rare to see the inflammation proceed so far as to cause ab-
scess, yet this accident is nevertheless sometimes encountered. The scrotum
becomes red, pouts, fluctuates in one spot of its extent, presenting every symp-
tom of a true phlegmon, or a posterne. The indication in this untoward event
is the same as in all inflammatory abscesses in general. Leeches, if it be
thought possible to prevent suppuration, poultices, and the puncture of the ab-
scess when its existence is evident, are iis principal means of treatment. On
the other hand, the tumor having diminished about one-third, one-half, or three-
quarters of the original bulk, remains stationary in that spot, and the cure is
incomplete. Then it is that topical astringents or discutients are singu-
larly serviceable ; frequently have they been known to conquer the indolence
of the disease, and complete the recovery at the very moment when recovery
was despaired of. If however nothing should be successful, all that remains
is to try the injection again, unless the solution should be taken to prefer
incision or excision. The method of injecting, as I have described it, calls for
no other precautions than those in the majority of cases. If however the
volume of the tumor be very great, such for example as to equal the size of
an adult head, or larger, it would be prudent to follow the advice given by
Schmucker, Boyer, and so strenuously insisted on by M. Bertrand ; that of
making small palliating punctures in the scrotum before the irritating liquid
is thrown in, in order to permit the scrotum to contract upon itself, and thus
diminish the extent of surface to be inflamed. If it were necessary to fill
with warm wine the enormous cysts which some individuals carry about with
them, we should have reason to fear, 1st, the reaction from so extensive an
inflammation ; and 2d, that it would be beyond the powers of the organizm to
effect the reabsorption of all the consequent effusion. I operated once without
any such precautions upon a man 48 years of age, whose hydrocele, a very
OPERATIVE SURGERY. 645
long standing one, was twenty -four inches in circumference. No accident
however occurred, and the cure was effected in the usual space of time.
During the tlirowing in of the stimulant injections, the patient usually suffers
pain of greater or less intensity, which takes the course of the cord and sper-
matic vessels, and which is considered advantageous, as proving the success of
the operation and that the irritation has reached a proper height ; which it is
satisfactory to find extending even into the side, or lumbar region, so that when
it is absent, an augury unfavorable to success is predicted. As all persons are
not gifted with equal sensibility, and as the tunica vaginalis may be either very
thin, or more or less altered in structure, this pain is experienced* in no
uniform degree. In aged persons, and in long standing cases when a decided
thickening of the cyst may be expected, it is well to heat the wine strongly,
and to render it rather more irritating than for those in reverse conditions. It
is not to be supposed merely because the pain spoken of is not present that
the operation will be unsuccessful : experience has shown a hundred times
the fallacy of such conclusions.
Unless the operator is extremely careful the point of the canula slips out
of the cavity of the tunica vaginalis with the greatest ease, during the empty-
ing and contraction of the scrotum, by the evacuation of the serum or fluid of
the injection. An accident so trivial in appearance as this, exposes the patient
however to the most painful consequences. The point of the instrument,
becoming insinuated between the tunics of the scrotum, the assistant unawares
almost inevitably forces into them the irritating liquid. The layers, connect-
ed by an extremely lax cellular tissue, oft'er but a feeble resistance to the fluid
which distends them. The result is a violent inflammation, which almost
invariably ends in gangrene, if not previously in the loss of the patient. To
a case of this kind M. Boyer was a witness ; the surgeon had committed the
canula to the charge of his assistant, while he himself threw in the injection.
The assistant not having following the retraction of the integuments by pressure
with the fingers, the wine all passed without the tunica vaginalis ; gangrene
supervened, of which the patient died. In 1824 I saw a similar occurrence
at the outdoor clinique of the school of medicine, where the injection was
forced into the thickness of the scrotum. The integuments and subjacent
tissues sloughed in almost the whole extent of the scrotum. The constitu-
tional symptoms notwithstanding were mitigated and the patient recovered.
This then is a serious accident against which we must strive to guard. Its
occurrence may instantly be apprehended by the local pain given by the
assistant in his attempts to force in the injection, by the resistance he meets
with, and by the elevations around the canula, which moreover is not felt freely
moving at its point within the elytroid tunic. The mischief being done,
we must without hesitation scarify deeply, and in several places, the scrotal
integuments in all their thickness, and even a little beyond the line of infil-
tration. The antiphlogistic treatment, and emollient poultices should first
be employed, after which if gangrene occurs or extends in spite of these
measures, local resolvents must be had recourse to.
This occurrence may also happen even when the injection has been fairly
carried within the tunica vaginalis. This is a fact not spoken of by writers,
but which apparently is not infrequent. Many persons have told me of cases
under their observation, and well informed pupils assure me that they have
646 NEW ELEMENTS OF
witnessed it in three hospitals in Paris, in one year. I have myself recorded two
remarkable examples. A man, sixty years old, who had a double hydrocele of
moderate size, was operated on by myself at the Hospital St. Antoine, in the
Spring of 1829. The puncture and injection were made only on the right side.
At first he experienced nothing beyond the customary pain. The first,
second, and third day, the swelling of the scrotum progressed in its accus-
tomed manner.
Nay, the inflammation was even feeble ; but on the fourth day we observed
a mortified point on the inferior surface of the swelling, whence, although I
lost no time in scarifying the parts, the gangrene marched on to such a degree
as to involve the scrotum entirely to the roots of the penis, and giving birth
to its usual concomitant symptoms.
We were, however, fortunate enough to conquer it. The sphacelated
shreds came away by little and little ; the globular tunica vaginalis, bare to
the bottom of the wound, appeared to fill up with a softish matter, as if
nothing uncommon had happened, and after much careful attention a cure
was effected ; upon that side also on which no operation had been performed.
In the second instance, treated at La Pitie, in the month of November, 1831,
no cause had occurred for suspecting that such a circumstance had existed, when
on the fourth day I saw appear on the front of the scrotum a large slough,
unattended by pain, redness, or any notable sign of inflammation. No re-
action was set up ; the mortified tissues were gradually cast off, and cicatri-
zation was insensibly perfected. To what cause are we to attribute the
reason of this gangrene ? Certainly not to effusion from the canula of a
portion of the urine between the layers which separate the tunica vaginalis
from the skin.
It is conceivable, that by too great a distension of the cyst by the injec-
tion it might easily be separated, so as to permit the transudation of a few
drops of the irritating liquid. I should not be astonished if this had really
been the case with the second patient of whom I have spoken. But as in both
cases the symptoms were delayed until the fourth day, it is scarce possible
to admit such a solution. The wiser course would be, at least in my two
patients, to refer the cause to their feebleness and a want of reaction, or the
state of alarm into which they were brought. Divarications of the tunica
vaginalis across' its fibro-cellular lining, which, as M. Dujardin has said in
his essay, must be easily effected, may naturally produce the occurrence I
have alluded to, and to them it has doubtless been more than once owing.
This simple statement, affords in my opinion a sufiicient reason why surgeons
should avoid distending the cy^t by their injection beyond what was effected
by the hydrocele itself.
I think also, that the use of too large a canula, by its leaving an aperture
large enough to allow the after-exudation of a few drops of liquid from the
tunica vaginalis, between its exterior surface and the skin, is likely to bring
about the difficulty in question, and that for this reason it should not hit
employed.
Two other accidents are also liable to occur in performing the operation
for hydrocele. The one hemorrhage, the other puncture of the testicle.
The form.er, first pointed out by J. L. Petit, and on which Scarpa has so
particularly insisted, can result only from three causes; 1st, from a wound
OPERATIVE SURGERY. ' 647
of the arterial branches sent off to the scrotum by the external or internal
pudics, and the epigastric ; 2d, from an injury of the vessels of the testicles ;
3d, from sanguineous exhalation on the inner surface of the tunica vaginalis.
From none of these causes it is easy to conceive any immediate danger. In
a natural state at least, none of the vessels are so large as to render its being
opened justly alarming. As to the steps to be followed, they are reduced to
opening the bleeding place largely, provided the duration of the evacuation is
such as to threaten serious consequences.
The second accident, viz., puncture of the testicles, arises only in cases
where it has been impracticable to ascertain accurately the situation of the
cord, or the seminal gland itself. Dupuytren, Boyer, and almost all surgeons
of extensive experience have witnessed the event. The pain which it causes,
besides being extremely acute, is of a peculiar character. The organ some-
times becomes violently inflamed, and may go on to suppuration. Still the
accident is less dangerous than might at first sight be imagined. A patient,
in whom this happened, and in whose testicle the end of the canula stuck so
fast as only to be detached by the injections, experienced none of the usual
concomitant symptoms of the operation by injection. Whereas in another an
abscess ensued, which I opened, and which for several weeks made me appre-
hensive of the loss of the prolific gland.
Congenital hydrocele, upon which Vigneni of Tours entertained the first
fixed views, requires a somewhat diflferent treatment. It is often sufficient
to return the fluid into the abdomen, and to prevent its return into the scro-
tum by a firm compress maintained for several weeks on the abdominal ring.
Some authors think so well of this proceeding as to suppose it renders all
others useless. There are individuals who cannot bear the remedy, or in
whom it is resisted by the disease ; such for example as those in whom the
testicle, notwithstanding the accumulation in the tunica vaginalis, has re-
mained in the abdominal ring, of which cases it would appear thatM. Dupuy-
tren has encountered a number. It is curable by injection, like the common
hydrocele, but its easy introduction into the peritoneum, would, it is clear,
expose the patient to very formidable risk, unless means were to be adopted
to prevent the occurrence. If then it is determined to practise it, we should,
in conformity with the advice of Desault, have an assistant to compress care-
fully the inguinal canal during the operation to cut off all communication
with the cavity of the abdomen, which compression might be subsequently
continued by means of an appropriate bandage, until the obliteration of the cyst.
A young man, seventeen years of age, on whom every other method of cure
had been tried in vain, was treated in this manner, in the hospital of Tours
by M. Mignot, in 1818, and with complete success. It is still to be feared
that in spite of the pressure the inflammation may travel from the tunica
vaginalis to within the peritoneum ; but it is well to state that these artificial
inflammations are for the most part rarely dangerous, not spreading as those
do which spring up spontaneously beyond the seat of the material irritation.
It would even seem that the introduction of a quantity of wine into the abdo-
men is not necessarily fatal. M . Jules Cloquet has published a case in which
a large part of the injection passed into the pentoneum notwithstanding the
care of the surgeon, but in which the symptoms were never such as to threaten
the life of the patient.
648 NEW ELEMENTS OF
If the hydrocele be an encysted one of the cord, injection might equally be
tried ; but as these cysts are usually composed of cells, and it is to be appre-
hended that one of them may extend into the inguinal canal and be ruptured in
the abdomen at the time of the operation, it is proper I think to give the
preference to incision ; until at least we have attained a positive certainty
that there is but one cell, and the limits of that one exactly defined.
In the female y hydrocele is so rare a disease, and of so little moment,
although mentioned by jEtius, by Paul after Aspasius, and by most subse-
quent writers, that it may be treated by injections, excision, cauterization,
and incision, and with a like chance of success as in the other sex.
The labors just published by M. Sacchi, added to the observations of
Paletta, Scarpa, and Monteggia, while they prove that its most common seat
is in the canal of Nuck, show also that it should be treated in women as in
men. In children the liquid of the injection should be less stimulating, and
heated to the temperature only of 28 or 30°. Old persons in whom the tis-
sues possess but a feeble vitality, and- the tunica vaginalis particularly is
little disposed to take on the adhesive inflammation, are ordinarily advised
to dispense with a radical cure, and to confine themselves to evacuating the
fluid at intervals by a simple puncture.
Where hydrocele is complicated with a hernia, it is obviously proper to
restore the intestine before making the puncture or injecting. Supposing the
hernia to be irreducible, every possible precaution, at least, must be taken to
determine the precise seat of the serous effusion.
If the descended intestine, accompanied by hydrocele should become
strangulated, it would be possible to cure both diseases at one operation by
kelotomy, properly so called ; taking care to open the tunica vaginalis freely,
as well as the hernial sac. Where it appears in an old sac, as Le Dran de-
scribes in a cyst upon this sac or any part of the scrotum, the same precautions
and treatment will be demanded as in ordinary encysted hydrocele.
When we are not permitted to attempt the radical cure, we have always the
palliative one to suggest. This, which consists in evacuating the elytroid
cavity by a puncture, repeated as often as the swelling becomes inconvenient,
has the additional advantage of resulting in some cases in an ultimate radical
recovery. A young physician has recently related to me the case of a patient,
who in eicht days was cured of a hydrocele which had lasted three years, by
running a long needle accidentally into the scrotum. I am not sure that
acupunctu ration is not considered as one of the radical methods of cure in
India. Moro, in England, has recently published a fact not less remarkable ;
that of a hydrocele which he cured in six days by piercing the scrotum, in-
cluding the tunica vaginalis, with a needle, which was left in the part as a
seton. Lastly, it yet remains to be seen whether methodical compression by
retractive plasters would not sometimes succeed in dispersing the aftection in
persons who will not submit, or who cannot be submitted to any of the methods
generally practised for obtaining radical cures.
§ 3. Ectomiay or AmjiUtation of the Scrotum.
The scrotum is at times attached by a degeneration, known to authors by the
names of " Glandular disease of Barbadoes," or of " Andrum," of " Elephan-
'operative surgery. 649
tiasis, or sarcoma lardacea of the scrotum, and for which ablation or removal
is about the only cure. M. Larrey states that he has often observed it in
Egypt, and calls it " oscheochalasia." This degeneration, so common in
India and some countries of Africa, has long remained unknown amongst us.
A proof of this is afforded by the history of the poor Marabout, so naively
related by Dionis. By those who would see the most accurate details on the
subject, the labors of M. Roux, the essay of M. Delpech, the w^ork of M.
Boyer,the Clinique Chirurgical of Baron Larrey, &c., maybe consulted with
advantage. Although surgeons were formerly in the habit of removing the tes-
ticles as well as their covering in performing this operation for the destruc-
tion of the disease of which we are speaking, the distinguished professor of,
Montpelier was not the only person who had remarked, that amidst this
singular disorganization, the genital organs remained for the most part unal-
tered, nor was he the first who projected the idea of preserving them and
confining himself to the removal of the morbid tissues. Numerous older
writers, confounding sarcocele and the other scrotal diseases under the
general head o( Jieshy hernia, ]\a.Ye expressly advised the protection of the
testicles, when found sound amid disease of the tissues. *' Let the skin," says
G. de Salicet, *' be sliced with a razor, then the carnosity thou findest there
be raised from the testicle, and leave the (testicle) if it be not wounded."
Altliough M. Roux, on the occasion of a fact such as that which now engages
our attention, had first proclaimed the principles on which M. Delpech has
so strongly insisted, the case of the latter gentleman, is still the most
remarkable yet known.
The patient was named Authier, an old soldier, and had long labored under
an elephantiasis of the scrotum, which had attained an enormous size, and
was said to weigh sixty pounds. The surgeon preserved all the integument
which could be saved from the root of the tumor, of which he formed several
portions of such a shape as to allow of his covering with them afterwards the
testicles and virile member ; dissected off these flaps and turned them up, one
on the hypogastrium, the others on the inner side of either thigh ; exposed by
the dissection, the penis, cord, and both testicles, each covered only by its
proper tunic ; wrapped the upper portion of integument around the penis as a
cap to cover it ; brought the latteral portion in like manner over the testicles;
and thus by the aid of numerous stitches, contrived to form a new scrotum,
and a sort of sheath for the generative organ. This splendid operation was to
all appearance attended with complete success. But the patient, who was
naturally very intemperate, and had moreover caught cold in going from
Montpelier to Perpignan, was attacked after the lapse of some months with
internal inflammation, wliich proved fatal.
"We are told by M. Larrey, that in 1816, in the presence of MM. Ribes and
Puzin, he pierformed an operation very similar to the above, from which it
differs only in so much as tiiat the tumor was but five or six inches in diameter.
It would appear also that the same surgeon had recourse to it in Egypt, in
which during his residence he thinks he has seen tumors of this character
weighing one hundred pounds. It would seem, too, that an operation which
made a great noise in its time, performed by Imbert de Lones on the minister
Charles Delacroix, was called for by a similar affection, and that it would have
been possible to have saved tlie testicle by simple ectomia of the scrotum on
82
650 NEW ELEMENTS 0^
the plan of Delpecb, instead of sacrificing it. It is proper to remark that this
affection does not appertain exclusively to the male sex. and that on a female
the operation would be infinitely more easy, and less dangerous. In fact as
no important organ exists in the mass which is to be removed, the extirpation
becomes quite as easy as that of a sarcoma, or cancer; on any other part of the
body, and this it is which accounts so perfectly for the success obtained by M.
Talrich, in the case which M. Delpech has recorded.
Our aim, in an ectomia of the scrotum, being to remove all that is diseased
and to preserve unimpaired all that is sound, the steps of the operation will
manifestly be liable to various modifications according to an infinity of circum-
stances : such as the size of the tumor, the involvement of one or both scrotal
sacs, and the facility which one situation or another affords for obtaining the
requisite quantity of integument for covering the denuded parts we are unwil-
ling to remove.
All therefore which can be said as to the manual proceeding, is that the
healthy coverings are to be looked for at the root of the tumor, so as to cut
from them flaps of a form and size sufficient and suitable before we proceed
to the removal of the diseased mass ; that avoiding these we are to penetrate
to the sheath of the cord, or to the tunica vaginalis, on the one side and oa
the other as far as the fibrous envelope of the penis, where the affection extends
in that direction ; the object being to strip these organs of all which surrounds,
and leave behind no remnant of morbid structure ; and with the understanding
that if the testes are found seriously affected their extirpation is to be on the
spot effected. An alteration is to be looked for in the increased length of the
spermatic cords.
It remains to be known whether this alone will justify the removal of the
seminal organs if otherwise healthy. M. Delpech is of opinion that it will not,
and that they will ere long resume their natural condition. I agree with him
in opinion, that Mr. Key might have avoided their excision in the patient
under his care during the last year, whom he relieved of an enormous scrotal
tumor. Can the same t)e said of the Marabout, operated on by M. Clot on
the 2rth March 1830, in whom the tumor weighed one hundred and ten
pounds, without counting a quantity of serum whicli escaped during and after
the operation. If with a tumor so large no hope of saving the testicles could
have been entertained, it might I think have been accomplished in the person
from whom Raymond removed one of the weight of twenty-nine pounds only.
The Egyptian patient of M. Clot completely recovered.
To conclude ; the only general rule which can be laid down on the subject
of ectomia, is the following. Remove the entire thickness of the degenerated
tissues, and preserve uninjured the important organs within, provided they
be in a natural condition.
Nothing can be said about the dressings, unless that the flaps are to be laid
down with all possible exactness over the parts they are intended to cover ;
that sutures, twisted or simple, are almost indispensably necessary to preserve
coaptation. They are to be covered with lint, and surrounded by compresses,
adapted to effect a moderate pressure in an equal and uniform manner upon
all the outer surface, so that between them and the subjacent tissues no spot
shall remain uncovered.
OPERATIVE SURGERY. . 651
c § 4. Castration,
This is an operation which has for a long time been advised only as a
remedy for intractable diseases of the generative glands. Happily in our
day it is performed no longer for objects of luxury, as was hitherto done all
over Europe. We no longer hear the act of Semiramis, who directed the
castration of all the feeble men of her territories, in hopes of having none but
robust and vigorous offspring, palliated by modern surgeons ; nor do they main-
tain, as did Brunus of Longo-buco, the right of masters to emasculate their
servants in order to render them safer protectors for their wives. Even
Italy herself has abandoned the brutal system ; introduced into her realms by
the popes, under the pretence of giving to man a softer and more melodious
voice.
For objects like these castration is no longer in use except in the East, and
in countries where slavery and polygamy are still permitted.
As a therapeutical resource it has often been put it practice in the radical
cure of hernia and of hydrocele. It was in old times a method much
resorted to, although by G. de Salicet, those who practiced it in his day were
denounced as ignorant ; and during the period of the writings of Cantemire
the Albanians themselves looked upon it as useless and dangerous. If the
practice was still prevalent among us within half a century, it would only, as
was observed when speaking of hydrocele and hernia, be among quacks and
persons ignorant of medical science. It is now never resolved upon unless
for diseases of the testicles themselves, and exclusively for such as are thought
otherwise incurable. It is employed for instance in cases where a bruise,
laceration, or some traumatic lesion has entirely disorganized the gland, when
it has began to secrete pus, or has become the seat of scirrhous, cerebriform,
colloid, melanotic, or tubercular degeneration ; but still with the certainty that
by no other treatment could the health of the patient be preserved. It is essen-
tial, to aiford any hope of success, that the affection be entirely local, uncom-
plicated with the viscera, and that no trace of it should elsewhere exist. Even
were the viscera to be found unaffected, it would be imprudent to perform the
operation in a case in which the cord was involved to any distance within the
ring. Still, if the degeneration were only colloid or tubercular — the result
of previous inflammations — with no mixture of scirrhous, encephaloid, or me-
lanotic disease, we might perhaps follow the cord either into the iliac fossa,
as did Le Dran, or at least adopt the recommendation of Lapeyronie and
seek for it in the depth of the inguinal canal.
Four different methods were in use among the ancients for performing cas-
tration upon healthy persons whom they wished to emasculate. Attrition,
which consisted in violently bruising the organs and thus produce its atrophia;
crushing, which was effected by squeezing it between blocks of wood ; ex-
traction, or tearing it forth ; and lastly excision^ were alternately preferred. Of
all these, still partially retained in veterinary medicine, the last alone remains —
and is that called by Paul, ectomia — ^in human medicine. The term cas~
tration, can then be understood to mean at the present day neither attrition,
squeezing, or extraction of the testicle. Ectomia itself, which is by no means
similarly performed by all surgeons, is thought by ma;iy capable of being
652 NEW ELEMENTS^OF
superseded by other methods infinitely more simple, and which I cannot
allow myself to pass over in silence.
Hie method proposed hy M. Maunoir, — Dr. Maunoir, a distinguished sur-
geon of Geneva, conceived early in tlie present century the plan of curing
sarcocele without the removal of the testicle, by baring the root of the cord
by the division of its enveloping coats, separating the vessels, and including
them in ligatures. Many successful results are stated to have been obtained
in this way; and within a short time a case has been quoted at the academy
of medicine, in which the operation was attempted with success. All that
can be attributed to this proceeding is, that by suspending the flow of blood
to the affected gland it may become atrophied, which appears to offer no
great gain to the patient. Reason would lead us to believe that, although it
might succeed in certain cases of degeneration resulting from a simple chronic
inflammation, in a genuine sarcocele it would prove insufiicient. To varico-
cele, which is serious enough to expose a patient to some risk, it would seem
much better adapted. For this all the ancients performed it, preferring
however to tie the veins. Paulus ^ginetus describes it in detail, in these
words; " we must protect the scrotum and the cremaster, tie the veins in two
places, and cut them between the ligatures." The same advice is given by F.
de Piemont and P. Forestus. And since 1820, Sir C.Bell has satisfactorily
shown that no inconvenience results from the artery and vein in a single
ligature. It is surprising that the Academy, and also M. Amussat, who
thought himself the inventor, should have imagined this to be of recent origin
when communicated to that body in 1828 and 1829.
Mr. Morgmi's method. — In England a somewhat different course was
adopted. Instead of interfering with the vessels Mr. Morgan recommended
the attacking of the vas deferens itself. Messrs. Lambert and Key, who adopted
the principle of this surgeon, each cite a successful case in its favor. After
having denuded the spermatic cord, they seek for and detach the vas deferens,
and excise a portion of it two inches in length, close the wound immediately,
and a permanent cure is speedily effected.
Did either of these methods encourage the hope of restoring the organ to its
original liealthy condition, or of preserving the exercise of its functions, it
would richly deserve to be adopted notwithstanding its uncertainty. Un-
fortunately this is not the case, and they will never I fear obtain that rank
in science to which some are willing to exalt them.
Castration properly so called comprises three distinct periods; 1st, that
of the incision of the integuments and covering tissues ; 2d, the section of the
cord and the application of styptic measures ; 3d, the dressings.
Period the 1st. — It is unnecessary, as has been said by Paul, to excise
any portion of integuments which remain healthy, or have contracted no
adhesions to the tumor, or when the tumor is one of small bulk. Beyond
this the first incision may be indifferently executed, either by a flap, or from
above downwards to deeper parts, as is done by most modern surgeons. The
incision is in either case to extend from a little above the ring and descend
to the bottom of the scrotum. Although some little more advantage be gained
by embracing the tumor at its posterior part, than by making tense the integu-
ments in front of the testicle during their division, as is recommended by M.
Dupuytren, this is more a matter of taste than of necessity. When once the
OPERATIVE SURGERY. 653
skin and its lining tissues are divided, nothing is easier than to insulate the
testicle by free strokes either with the fingers in imitation of Benjamin Bell,
with scissors, or what is infinitely better with a convex bistoury, until the
whole circumference shall have been completed.
The assistant tlien separates the lips of the wound, while the operator with
one hand seizes the tumor, or vice versa, in order to stretch the parts to
separate them in the suitable direction whilst tlieir adhesions are destroyed
with the other hand. The only precaution necessary to be taken, is that of
not carrying the knife too near the penis or septum of the dartos for fear
of wounding the urethra or the testicle of the other side. There are many
surgeons who are of opinion that this plan should always be followed, however
large the sarcocele, unless the integuments are diseased. The proceeding
is liable to real inconveniences, and to remove a certain portion of skin with
the testicle, when the bulk of the cancer exceeds certain dimensions, which is
the mode advocated by Sharp and De la Faye, and long before practised by
Paul of Egina, is undoubtedly a preferable one.
An elliptical incision, carried like the former, from above the ring to the
lower part of the scrotum, should in that case be made to include a cuta-
neous portion, large or small according to the size of the testicle. In the
fear that pus might stagnate in the incision, and wishing to avoid the scar in
front, and being also of opinion that the morbid alterations of the skin were
more frequently met with below than above, Aumont has recommended that
the incision be made on the inferior surface of the tumor, and not on the
anterior as it is usually made. There is no doubt that this advice may be
followed; I have seen it done by M. Roux, and have twice done it myself.
When the integuments are perfectly sound in that part in which it is usual to
incise them, while they are more or less disorganized in the opposite situation,
this method may even be strictly accurate. But how childish is it to attach
the least importance to the scar being in front rather than behind, under the
idea that it is more visible from above than below ! With regard to the stag-
nation of pus, experience is sufficiently ample to prove the facility with which
matter will escape by the incision when made according to the old method ;
whilst that of M. Aumont presents so serious an objection in the greater dif-
ficulty with which the cord is insulated to within the inguinal canal, that I
once saw M. Roux sincerely regret that he ever adopted it.
Period the 9>d. — As soon as the dissection has surrounded the tumor,
and the cord is denuded to the extent of the disease, the surgeon is to attend
to separating the parts which it is his intention to remove.
Upon this point of practice it is, that the greatest discrepancy in medical
opinions exists, from which two very different methods have resulted. In
one, the cord or its vessels is tied before the section of it is made ; in the
other, a plan totally opposite is pursued ; each containing many diversified
proceedings.
Method 1st, is that recommended by Paul of Egina, who included the
whole cord, by the advice of Celsus, in one strong ligature, placed between
the diseased mass and the ring. Most operators at every period have pur-
sued the same course ; though some, following Purmann, advise the location
of the ligature as near as possible to the ring ; while others again, with Bar-
bette and Bertrand apply it immediately beyond the epididymis. Some,
654 [^NEW ELEMENTS OF
Haenel among the number, place it at a distance intermediate. Some are
found who, at the recommendation of Franco and Pearson, draw the ligature
at once with great tightness, while others, as 0. Acres, compress it just
enough to impede tlie flow of blood. Gcauthier, for instance, is among those
who tighten it only by degrees, increasing a little each day until it cuts
through the tissues completely. Pare, and a large number of others, advise
us to pass a string several times doubled across the cord, cut it into halves, and
separately tie each portion. Ravaton, wishing to leave the vas deferens
entirely free, places his ligature in the same way as Pare, but ties that por-
tion only which appears to him to contain the vessels. Some surgeons,
agreeing with Birch as quoted by Sprengel, carry a ligature up underneath
the parts to a considerable height, and put on another an inch below it, with
which they compress the vessels before cutting through the parts beneath.
Lastly, we must further remark, that it has been deemed advisable by Theden
and Flajani, to interpose a small compress between the ligature and spermatic
cord, while by Pelletan a simple plate of lead is preferred to the compress.
Method 2d. — Those who first remove the organ are not less divided in
opinion as to the attention to be afterwards paid to the cord. Cheselden, from
an observation he had made of the vessel being entangled by the ligature on
tiie cord slipping before it, and the hemorrhage checked, was one of the first
to propose the ligature of the arteries only. Le Dran preferred to protect
them with a ligature placed beneath, to rub them between the fingers at some
distance below, but to tighten the ligature only in case the friction should
prove insufficient to arrest the hemorrhage. White and Korb assert the suc-
cessful imitation of this practice. J. L. Petit applied a small graduated
compress upon the ring and employed no ligatures, while Ponteau was
content to turn the end of the spermatic fasciculus over on the pubis. Runge
equally dispensed with a ligature, by twisting the cord on itself several times
after a cautious dissection before he cut away the gland. Smett, Schliting,
and a multitude of others, declare that all these are futile precautions : that
men who in fits of anger or despair castrate themselves employ no such
measure, and yet do not perish from hemorrhage. It would be a mistake to
fancy that this diversity of opinion existed no longer in our own time. Liga-
ture of the mass retains many advocates, though there are many surgeons who
do no more, than to insulate and tie each vessel separately before cutting away
the testicle from tl e cord. Bicnat, M. Roux, and Sir C. Bell, have advised us
to cut every thing away but the seminal canal, then to seize and tie its arteries,
and afterwards to cut the vas deferens itself. Others cut away the sarcocele
as soon as they have dissected it away from its connections and coverings, and
immediately search either with a hook, tenaculum, or with forceps, for the
bleeding vessels in the upper cut extremity of the cord. It is surprising
that so much discussion should have been carried on, and still continued, as to
the relative value of a measure, the choice of which is itself such a perfect
matter of indifference. In most individuals, the artery or arteries of the cord
being so small as to be left to themselves after they are divided without any
danger, it appears to me that Le Dran's friction, Petit's compression, torsion,
or the turni.ig over of Runge, will all answer, and may be tried by any one
so disposed without risk. Nor can I deny the probability of equal success
of ligature, in the manner of Boyer, Dupuytren, Delpech, and Roux, who have
OPERATIVE SUKGERY. 655
adopted the principles of Cheselden and Bromfield. The cure will ensure
equally well whether the cord be entirely constricted or only partly; and
whether the pressure be gradual or immediate. The chief point is simply to
ascertain which is the easier and safer of the two, to tie the whole in one
ligature, or to apply no ligatures until after the removal of the mass.
Siebold, had the other antagonists of the former method, ground their
rejections to it on the danger which is sometimes incurred by including in one
ligature the vas deferens, the strings of nerves from the venal plexus which
accompany it, the branch sent off by the genito-crural nerve, and the other
tissues whose incision is not indispensable, on the fact that such a ligature
must produce violent pain, and incur the risk of convulsion and even of
tetanus, and lastly, on the length of time which sometimes elapses before it
cuts through the part and can be removed from the wound. Some have even
added, that constriction of so great a quantity of different substances, will
soon produce loosening of the string, which would be insufficient to close the
arteries.
To this it maybe replied, that the strangulation does but cause an acute pain
for a second, even when it ruptures the continuity of the nervous filaments
and of the vas deferens ; that hemorrhage has never been seen to proceed
from vessels thus strangulated ; that tetanus and other nervous calamities are
no more to be feared from this than from any other method ; that the patient
treated by this method by Morand, and who died of locked jaw, the disease
was induced by a wholly different cause; and that in addition to all this, a
case has been published in the Review Medical by M. Couronnee, of a
person who died with tetanus following castration, although the spermatic
cord was not included in a general ligature. I have seen the thing done at
least twenty times within four years, at the military and civil hospital at Tours,
by M. Gouraud ; by Richerand and Cloquet at the Hospital St. Louis; by M.
Bougon at the Hospital of the School ; and likewise by many other practi-
tioners. I have done it myself in nine cases ; and in all these cases, fifty or
more in number, the general ligature was employed without the occurrence of
a single accident which could be referred to its use. The observation of
Mursinna, Wilmer, Loder, and Dietz, have likewise refuted the objections of
Siebold on this head.
Suitable precautions being taken, a successful result from separate ligatures
is, it is true, not less frequent; but it is clearly attended with rather more
difficulty, as it is not always easy to discover the vessels, as the frequent
searches for the purpose lengthen the operation uselessly, and as dangerous
hemorrhage has sometimes arisen from the ends of the arteries after this
treatment.
There is peculiar to this mode an inconvenience which may equally create
anxiety, and which I saw happen in a person on whom M. Roux operated.
Whilst the professor was in search of the artery, the seminal fasciculus
escaped from his fingers, and ascended high up beneath the preserved
integuments ; haste was made to seize it with forceps and to bring it without,
to be included in ligatures which were placed rather uncertainly. The he-
morrhage appeared to be suspended, but towards evening an abundant flow
of blood became evident, was repeated frequently throughout the night, and
threatened to prove fatal. Much has been said by authors about this dispo-
656 NEW ELEMENTS OF
i
sition in the cord to retract itself; and hence the use of preventive ligatures
and a host of other precautions designed to guard against a similar move-
ment.
Nevertheless, no constituent part of the cord is contracted. The testi-
cular vessels and vas deferens, lengthened more or less by being dragged
down by the suspended weight, only appear capable of retreating towards the
abdomen when they are relieved of their burden. It does not appear how the
enveloping or covering tunics can operate the least reaction in this direction.
The fibres of the cremaster at the utmost could raise it but a few lines. It
is incorrect then to say that when once free the cut extremity ought to
ascend considerably upwards. Nor is this tendency in it now for the first
time denied. A long while ago the error had been corrected by M. Flaubert,
a distinguished provincial surgeon ; M. Senateur has stated in his essay many
facts to overthrow it, and Mr. Charles Bell has combatted it in England. The
following is all that happens : if, by the long standing of the sarcocele, its size,
or any other cause, the cord has been considerably elongated, as soon as its
division is affected it tends indeed to gain the inguinal passage ; but the parts
do but yield to their own elasticity, and only to approach a little nearer to
their primitive situation. Nothing like this happens when no elongation of
the cord exists, when the diseased testicle maintains its original distance
from the ring; and then the retraction spoken of is in nowise to be appre-
hended. To conclude our investigation, it can only become of consequence
in a few individuals as when we cannot separate the cancerous mass at least
an inch from the ring ; whence it follows that it is scarcely necessary to heed it
when the cord itself is unaffected by the disease. Arnaud, Marechal, Garen-
geot, Bertrandi, and others, having remarked its root to be surrounded by
fibrous tissues and tense lamina, thought that the ring should be relieved of
these bridles, so as to prevent strangulation, to which they attributed nu-
merous dangers ; but which must be of rare occurrence, since it is unnoticed
by any modern authors, notwithstanding the general neglect of the advice
given by Garengeot.
The manner of dividing the cord could undergo but little alteration. ^ The
hot iron preferred by Roger de Parme, Brunus, and others, finds defenders no
longer. The scissors recommended by Scultetus are evidently less conve-
nient than the bistoury. In using the latter instrument, the recommendation
of Leblanc to make the incision in the form of the mouthpiece of a flute is
useless. While the testicle is supported by an assistant, the surgeon seizes
hold of the cord with the left hand a little below the ring or the spot upon
which the ligature is, and cuts it at one blow from behind forward, or from
before backward, perpendicularly to its axis. It is not likely that hereafter
the division of this organ will be trusted to the thread as a means of detaching
the parts by insensible degrees, as if we were treating a polypus, which is the
plan proposed by Runge or Leblanc. If the lips of the wound, by being too
large and extensive, should be longer than is proper to admit of their approx-
imation, it would be proper to resect them immediately, otherwise they will
roll inwards and render the healing long and difficult. This tendency of the
sides of the scrotum to be turned inward seems naturally explicable by the
arrangement of their anatomical elements ; the remains of the cremaster, if
it be not wholly destroyed, and the layer which constitutes the dartos, being
OPERATIVE SURGERY. 657
to a certain extent endowed with the power of contraction, retreat more or
less upon themselves, dragging necessarily the cutaneous tissues with them in
the same direction.
Procedure of Zeller or of Kern. — A certain surgeon, Acoluth, fearing hemor-
rhage beyond all things, conceived the idea of obtaining a gradual sloughing
of the tumor, by drawing down the tumor from below and strangulating it at
its root by a silken ligature placed above it. Aristotle and after him Haly
Abbas, advise the excision of the testicle by a razor carried beneath the sus-
pending part. In Germany the plan is somewhat differently effected. Having
noticed the fact that maniacs and others amputate their own testicles and
scrota at a single stroke, it occurred to Zeller to convert the idea into a
regular method of operation. His plan is to embrace the whole sarcocele
with the left hand, causing an assistant to draw up the integuments on the
upper side with his hand, he cuts away at a single stroke of a scalpel or bis-
toury the whole cancerous mass stripped of its coverings, and merely places
a sponge dipped in cold water at the bottom of the wound to guard against
hemorrhage. A surgeon of Vienna, since desirous of extending the method,
has put it frequently in practice, and as he says with uniform success ; but
with a most important modification however, since he never lets go the cord
until it is surrounded by a strong ligature.
The method of Zeller allows of the removal of the testicle with won-
derful celerity, and renders castration as simple as it is easy. And I have
thought that as the integuments have not been dissected off, it is possible to
close the wound much more quickly than by the usual method. But it ren-
ders general ligature of the mass of the cord rather more difficult, and evi-
dently ceases to be applicable where the disease is rather large or its envelopes
are in a morbid condition. Instead of occupying the scrotum, or banging
pendulous without, the organ to be removed may be retained within the thick-
ness of the abdominal parietes in the inguinal canal, either because it had
never descended into the scrotum, or because it had afterwards accidentally
reascended, of which a remarkable instance is related by Rossi. In some
manner.or other it may then change into sarcocele, as proved by the examples
adduced by Chopart, Boyer, and Robert. Then we see how difficult and
dangerous must be the operation. How are we to judge before hand of the
condition of the cord ? how define exactly the extent of the disease ? It is
to be feared also that the peritoneum may be opened contrary to our wish, as
happened to M. Nsegele, or that it might be necessary designedly to cut through
it in order to remove the entire disease.
Under these circumstances it is necessary to cut through layer after layer
all the coats which envelope the tumor ; isolate it gradually by a cautious dis-
section, and keep carefully in mind the proximity of the peritoneum, of the
epigastric artery, and even of the iliacs themselves. The cord being arrived
at, I think it most prudent to include the whole in a general ligature than to
tie each vessel separately. But if the tissues should be much altered by the
chronic inflammation, and confounded with neighboring parts, this species of
ligature would then deserve the preference, and the string should be passed
with the assistance of crooked needles. ^In a case related by M. Puisser, it
was necessary to divide the cord more than three inches above the ring, and
the patient notwithstanding recovered equally well.
83
658 NEW ELEMENTS OP
The wound resulting from the ablation of a testicle, by any method of
operation, contains always a number of vessels which claim the surgeon's
attention before he proceeds to dress it. Exclusive even of those of the
cord, one or two are usually to be found without, and these generally
the largest; the inferior angle of the incision has some also, which are given
off from the pudic by the superficial perineal artery. It is not uncommon
to find one on the inner surface, which is a branch of the artery of the
septum of the dartos. Usually before the operation is over these vessels
have done bleeding, and in some people we look for them afterwards in vain ;
hence the caution to pause and twist, or tie them as they are cut. However,
if they do not reappear beneath the sponge used to detect them on the surface
of the cut, they rarely result in hemorrhage when abandoned. Also, if they
be tied, and they are then thought secure, we must be aware that during the
night following, or in three or four hours afterwards, the dressings become
soaked with blood without the existence of actual hemorrhage.
TheManner of Dressing. — The ancients often had recourse to sutures, and
endeavored to effect union immediately after the removal of the testicle.
Towards the end of the 17th century however, union by the second intention
was alone attempted. A number of English, German, and American surgeons,
M. Delpech, and other surgeons practising in the south of France, are it is
true, endeavoring to establish the former method ; but I have not seen either
in Serre's book, or in any foreign works, any well established fact of complete
cicatrization directly occurring in such a wound.
To be really indispensable, sutures, simple or twisted, must be confined
to cases in which no ligatures are put on any of the vessels and mere torsion
has been practised, so that the cut edges may be placed together accurately,
and the preserved integuments upon the subjacent tissues ; whence arise nu-
merous difiiculties to be overcome and more pain to be endured. The usual
mode of practice offers infinitely fewer difiiculties. A fine peice of linen,
pierced with numerous holes and spread with cerate, is spread like a veil over
the wounded surface : over which some small balls of lint are to be laid. The
sides of the scrotum are likewise to be protected by lint, lest they should
strike the upper parts of the thighs. Several lint compresses (plumasseaux)
are to be laid over the whole. Some long compresses, a large suspensory or
double spica bandage completes the apparatus and the dressing.
The accidents which it is to be feared may occur are the same that follow
all other great surgical operations sometimes, and require the same treatment.
Hemorrhage when it happens does not always acquire the precipitate re-
moval of the dressings to discover its origin and secure the vessels. It is
often all-sufficient for arresting the bleeding, to sprinkle or bathe them in cold
water, or with the aq. saturni, and renew the application every hour at
least. Should the flow continue, however, to such an extent as to weaken
the patient or lead to the belief of an internal effusion, we must take
off the apparatus without hesitation, remove the clots of blood, and tie the
open artery or arteries ; or else when the danger is urgent, resort to styptics,
the tampon, or even the actual cautery itself. Where a general ligature has
been applied to the cord, and the constriction has not been quite sufficient
to strangulate entirely the tissues, the end of the cord may return its vitality,
and be converted into a reddish or cauliflower excrescence, which, as
OPERATIVE SURGERY. 659
was remarked by J. L. Petit, and as I myself saw happen in a person operated
on by M. Cloquet at the Hospital St. Louis, may connect itself with the neigh-
boring edges of the wound, so as in the sequel to give rise to some difficulties.
It is indeed probable, even then, that the ligature would end by cutting through
the stem on which it is placed, and all that would be necessary would be
to repress the growth of the vegetation by astringents or caustics.
If in spite of every precaution the edges of the wound should turn out-
wards, and the suppuration prove too copious, we should endeavor, to approx-
imate its fundus, and by maintaining compression on its sides, to bring about
their union by the second intention as speedily as possible.
Art, 2. — TTie Copulative Organ.
§ 1. Phymosis.
Contraction of the prepuce is a disease which presents itself to the surgeon
under three principal forms. When congenital^ it is troublesome only as an
impediment to the flow of urine ; in adult age from the pain which is occa-
sioned by it during coition ; as an effect of active inflammation it may give
rise to serious accidents ; when accidental, hut of a chronic character, the
entire prepuce may be hardened and thickened, so as to form a hard, inelas-
tic, lardaceous shell, extending beyond the gland to a greater or less distance,
which it closely embraces.
A congenital phymosis which depends, as is the case in children, on an
undue length of integuments, demands no other operation than that known
?ind practised by religious precept among the Jews and nations of the East,
called circumcision. Neither do those cases which result from acute in-
flammation, such as chancres and venereal lesions of any kind whatever, call
for the emplojrment of instruments, unless they render the original affection
too difficult to be cut, or cannot be conquered by injections, topical applica-
tions, and other appropriate means.
The third species is one but little noticed. When it is of long standing,
and of such a nature as to cause difficulty in voiding the urine, no other aid
can be rendered than that which is affi)rded by the division of the contracted
circle. The operation is in all cases the same, and it is needful only to
remark, that when performed upon a prepuce on whose inner surface ulcera-
tions exist, the wound itself will commonly ulcerate, and that then the use of
antisypliilitic measures, local and general, must not be forgotten.
Anatomical Observations. — The penis is inclosed in a tegumentary layer,
soft and flexible, which in its reflexion to form the prepuce, becomes insen-
sibly a mucous membrane on the corona glandis ; and is lined throughout
with a lamellar tissue so supple, lax, and distensile, that it may be drawn
backwards or forwards to a distance of several inches. This arrangement, so
consonant with the functions of the penis, renders it easy to lengthen, too
much or too little, the external layer of the preputial sheath, although by
itself is total division would have been exactly of the right dimensions ; that
is to say, if during the incision the skin is drawn forward, it will be seen to
draw back and uncover a portion of the copulative organ ; while on the other
660 NKW ELEMENTS OF
hand, much more retracted in an opposite direction, it would return apd cover
the posterior extremity of the wound. The vessels, which come off from the
dorsal arteries of the penis, and sometimes from a prolongation of the artery
of the septum or the superficial perineal branches, are found principally on
the upper part and inferior extremity of its vertical diameter; so that in pro-
portion as we deviate from the median line is the risk of hemorrhage increased.
Happily, as their volume is inconsiderable, they need give no anxiety in this
respect, and scarcely merit attention. Lastly, let it be remembered, that in its
downward reflection to form the frenum preputii, the prepuce gradually ex-
tends its adhesions from the corona glandis towards the meatus urinarius^ to
such a degree as to offer a much greater length in this direction than in
the dorsal side.
The Operation. — Superior Method, The operation forphymosis, as simple as
any in surgery, requires for its performance a narrow bistoury, either straight
or slightly concave, or a pair of scissors : a director grooved to its extremity
and not ending in a cul-de-sac, dressings forceps, artery forceps, a lint com-
press besmeared with cerate, two or three small soft compresses, and a narrow
bandage about a yard in length. The concealed bistoury of Bienaise, employed
by Lapeyronie, as well as all instruments specially devised for this object,
are wholly useless.
The patient is to be seated on a chair,, unless he prefers being in bed. The
surgeon, in a convenient, position, passes the director beneath the prepuce
down to the bottom of the gland. The assistant who supports the penis is
now desired to attend to the director also, and to preserve it and the integu-
ments in a proper position. The bistoury, gliding over the groove in the
director, reaches the base of the cutaneous fold or replication ; when its point
is turned towards the skin, so as to pierce the prepuce from within outwards, ^
and then rapidly to cut it through from behind forwards. The incision by
puncture of the deep seated parts near the skin possesses the advantage
mentioned by M. Richerand, that the patient by shrinking involuntarily him-
self, completes the operation without trouble to the surgeon. In order to
dispense with the grooved director many persons follow the advice of Saba-
tier, conduct the bistoury flatwise in between the glands and its sheath, and
then act as has just been directed.
Some also, to avoid wounding any parts over which it passes, place a small
wax ball, smeared with oil or cerate, at the end of the bistoury, which when it
arrives at the bottom of the cul-de-sac, passes easily through the wax and the
integuments to be divided together. Scissors are now scarcely any longer
made use of; acting as they must on very soft and unstable parts, they rarely
effect more than a partial division only at the first cut ; and the more so that
the incision must be made from before backwards. They are consequently
employed only to rectify the incision made by the bistoury when it has not
equally effected both layers of the prepuce, or when it is wished to add to its
length. , >.'
Some other surgeons think it necessary to adopt infinitely more minute
precautions, for the purpose of limitirtg the too great extent of the wound,
whether inwardly or outwardly. For example, it is the advice of M. Ricord
that we should seize the tegumentary fold with two, or even three dressing
forceps, in three different places from its free extremity to its base, so as to
Ol»ERATIVE SURGERY. 661
Stretch it sufficiently, and to allow its section to be made by the knife, or
scissors, xvithout danger of the two layers sliding over one another. Besides
the inconvenience of such a multiplicity of instruments, which require to be
managed by as many assistants, it has moreover this objection, that it is very
rarely admissible for a prepuce sufficiently contracted to call for the opera-
tion ; for phymosis would never admit the introduction of three dressing forceps
and a cutting instrument. When we have been careful to drawback the skin,
that no folds or twisting may exist on the free edge of the prepuce, and the
assistant or surgeon has been watchful sufficiently to stretch the part, the
obstacle (which the plan of Lisfranc, as described by M. Ricord is well cal-
culated to obviate) will be but little to be feared. The former of these
surgeons, with a view of avoiding the angular projections of the wound,
advises us to do no more than excise a semilunar portion on the anterior and
dorsal border of the part, which he does with scissors curved on their flat
surface ; and which excision he repeats in several places along the membranous
circumference, if the first section seem insufficient. This procedure, which
is useful when the prepuce is long and the malady slight, should however be
superseded by the removal of a triangular portion of the contracted ring
when any solid advantage is to be gained by a loss of substance. This latter
excision would, in fact, be indispensable in operating on a phymosis resulting
from chronic induration, as I myself once did at the Hospital St. Antoine, on
an individual who had the sheath of the glans converted into a really fibro-
cartilaginous shell.
By a preference to the dorsal region, which is advised by most operators,
we are liable to extraction of the sides of the incision and their lateral sepa-
ration from each other, so as to give rise to a very ugly looking rim or edge,
which is also sometimes a ver^'^ troublesome one.
Subsequent excision of the angle of each portion does but very imperfectly
remedy the defect of which I speak, and in all cases is far from sufficient. To
this result, the method invented by M. Cloquet gives an infinitely less predis-
position. It is performed by making the incision at the lower and the upper
part of the prepuce. The bistoury is carried on one side or the other of the
frenum, which is itself afterwards divided if it appears to be lengthened too far
forward. Besides having fewer vessels to encounter in this than the former
direction, the wound becomes transverse by the retraction of its edges, which
is all in favor of the aperture we desire to augment, and does not leave a de-
formity as in the preceding case, equally as troublesome as the original affec-
tion. It would appear that phymosis was thus remedied by the ancients, for
in speaking of it Celsus remarks, " subter a summa ora cutis inciditur, recta
linea usque ad frenum, atque ita superius tergus relaxatum cedere retro po-
test." I have performed this operation eight times, and experience leads me
to the belief that it will be a substitute for the other.
Instead of making the incision on the median line, either above or below, we
are sometimes induced by the presence of veneral tubercles or ulcers to place
it on the side, or on both sides of the organ ; but to render this necessary, the
prepuce should be extensively altered, as lateral incisions are in general
attended with great deformity. It is possible, and sometimes very useful
when the constriction extends to a considerable distance, to strike the point
of the bistoury in upon the director through the integuments, as is advised by
662 NEW ELEMENTS OF
MM. Heurtault and Tavernier, and not as is usually done, make the puncture
from within outwards. Another good rule, also laid down bj M. Tavernier,
with a view to avoid any error in calculating the relative extent of the incision
into the organic layers, is the following; the director once introduced, its
point is made to project a little ; the surgeon then is to draw back the skin
until the rosy border of the mucous layer be distinctly seen. The points
being kept in this position by the operator himself or an assistant, he may be
sure that the instrument piercing the integuments from the surface to the
director, or from the director to the surface, and brought back from the root
of the prepuce to its free extremity, will make as neat and even a section as it
is possible for it to do.
The operation being completed, the cutaneous replication ascends behind
the glans penis. The lint compress is laid on the wound, which is surrounded
with a small soft, and two long compresses, or a Maltese cross ; to conclude,
the bandage is carried down to the extremity of penis, so as to bring it
back by circular turns to the anterior extremity of the organ, and again carry
it behind where it is to be fastened. A suspensory previously applied
would allow this little arrangement to be much more securely effected, and
render it much less liable to derangement. It is well to take a turn or two
of the bandage or to pass a cravat around the loins; the whole organ may be
kept turned up on the hypogastrium. If the dressing be not displaced, it need
not be renewed for two or three days ; and if suppuration takes place it is
really so simple as to require me to dwell no longer upon it. That the wound
may remain as narrow as possible in the antero- posterior direction, and may
not be tedious in healing, there is some advantage, particularly at the first
dressing, in placing the folds or turns of the bandage on the body of the penis,
going from behind forwards ; and also, in afterwards using, as is advised by
M. Tavernier, a Maltese cross perforated in the centre, so that it may leave the
glans uncovered while it pushes the divided prepuce from before backwards.
By these means the dressings are more solid, and all the tissues are drawn to-
gether instead of tending to a separation, as often happens when this precaution
is not taken. At a later period I have found it a good plan to draw forward the
callous rim which is formed for a good while by the edges of the incision, so
as to compress it a little and favor its absorption.
§ 1. — Paraphymosis,
If compresses steeped in cold or iced water, which have the property of
overcoining strangulation and allowing the prepuce to be drawn over the
glans, by reducing the bulk of the cavernous bodies and diminishing the
flow of blood into them, are insufficient or cannot be employed, and unless
the inflammation or painful state of the parts themselves render it inexpedient,
we can always try what can be done by another means before resorting to
the operation properly so called. This means is compression. By some it is
executed by the use of a roller bandage, gradually increasing its power until
the reduction of the glans can be made ; others operate with their fingers, in
such a manner as that the patient is for the most part immediately cured of
the affection.
To do this, the surgeon seizes the penis with the index and middle fingers
OPERATIVE SURGERY 663
of either hand, which he crosses behind the morbid ring of the prepuce. His
two thumbs remaining at liberty, are to press upon the sides of the glans in
such a way as to act in concert with the fingers, but in opposite directions,
the glans being pushed strongly back, whilst the prepuce is drawn forcibly
forwards as it were to cover the thumbs which are crowding within it. That
the fingers may not slip on the skin, it is well to cover each with a piece of
thin linen, which has besides the advantage of rendering the operation rather
less painful. It would be wrong to refuse a trial to this remedy on the sole
ground of the disease having lasted twelve or eighteen hours, and that tlie
parts are swelled and painful. I have resorted to it with perfect success
twenty hours after the accident, in a healthy and robust young man twenty-
five years of age ; and after the lapse of three days in another, and with no
more convenience, although the forepart of the penis was extremely sensitive
and that several chaps existed on each side of the rim of the prepuce.
This is an operation likely to succeed in the greater number of cases when
it is well performed, but of which the mechanism is too simple to require its
explanation at greater length to a person intelligent enough to do it as it should
be done.
If it do not, however, answer the object of the surgeon, we must resort to
the use of cutting instruments. Whilst an assistant holds the penis at both
ends, and bends it moderately upon its inferior surface, the operator slides
a narrow bistoury flatwise between the dorsal aspect of the glans, or of the
corpora cavernosa and its coverings, as far as the strangulation ; turns its
edge towards the skin if sure of having penetrated beneath the constriction,
and in the contrary case towards the penis ; and then in the former case by
depressing the wrist, in the second by elevating it a little, he cuts it immedi-
ately, and if one incision does not appear sufficient makes one or two others in
a similar manner.
Now, instead of thus ploughing up the tissues to reach the stricture, would
it not be better to incise it at once by its outer surface ? I see nothing to
render such an operation impossible. In endeavoring to push back the skin
towards the pubis, and to turn out the morbid rim in front, the bottom of the
circle which causes the difficulty is generally brought into view. Nothing is
then easier than to carry down perpendicularly upon it the point of a straight
bistoury held like a writing pen, and to make in one or more places with
the instrument little incisions, to which the necessary depth may be given
without running the risk of erring as in the other method. I give the preference
to this method, and with me it answers so well, even in the case of a child in
whom the paraphymosis was of three days' standing, and in all the adults in
whom I could not relieve by the fingers and thumbs, that I can scarcely
conceive of a case in which the former method need be indispensable.
A little lint spread with cerate, lotions of marsh-mallows-water, emollient
topical applications, and the most soothing means, are all that is called for
after this simple operation, which can only be rendered serious by opening
largely into the corpora cavernosa, or by the division of a principal artery of
the penis ; even then such occurrences would probably prove unimportant.
664 NEW ELEMENTS 01*
§ 3. Stricture of the Penis.
. Since the attention of the profession was directed by Morand to this sub-
ject, all practitioners have mentioned individuals who from depravity or
carelessness have mechanically included the penis in bonds or rings, from
which they could not afterwards withdraw it. Sometimes it is a ring of cop-
per or iron, a circle of gol(l, silver, or iron, a metallic ferrule ; at other times
a piece of pack thread, a riband, or even, as was seen by M. Dupuytren, the
socket of a candlestick ; again, it is an elliptical steel circle, called a *'steel,"
which such imprudent persons pass over the penis so as even sometimes to
include the testicles themselves. The parts speedily react upon obstacles
like these, which are soon buried in a fissure of greater or less depth ; and
which by exciting inflammation and tumefaction, are promptly followed by
perforation of the urethra, or of .the fibrous tunic of the corpora cavernosa,
if not by sphacelus itself. Ligatures of thread, cord, or riband, will never
seriously embarrass a professional man ; the point of a bistoury, or a pair of
very sharp scissors being always able to overcome the difficulty, and the same
may be said of rings, of rushes, osier or wood. To disengage a circle of ebony,
ivory, or horn, scissors of great strength, or cutting nippers, are necessary.
The file and the saw become indispensable in the division of metallic sub-
stances. A cutting diamond in such a case would be invaluable if it were at
hand. Unless it were of extraordinary thickness, the hardest circle would
not prx)bably resist a couple of small hand -vices if they could be applied
to it.
If the swelling of the part be excessive, the congestion is to be lessened by
the previous employment of scarification and punctures. The sides of the
fissures are then to be separated as far as possible, so as when practicable to
admit beneath the stricturing body a flat piece of linen or metal, as a protec-
tion to the parts against the action of instruments. The saw and file are to
be used across rather than in the long direction of the penis, and the use of
the other means is sufficiently intelligible without entering any further into
useless details.
§ 4. Section of the Frenum.
The frenum of the penis, like that of the tongue, sometimes projects too far
forwards. The result of this, in certain subjects, is, that during its erection
it is curved downwards to such a degree as to render coition painful, and emis-
sion difficult. The remedy for this inconvenience is so easy of application,
that all persons almost adopt it. In the first place the abnormal fold fre-
quently gives way of itself in coition. If it resists these efforts, it must be
divided either with scissors, or a bistoury. The glans being raised up by the
patient or an assistant the surgeon has only to draw down the prepuce, and
if he uses scissors cut the frenum as far as possible from before backwards
at one stroke. If a bistoury be preferred it is immaterial whether the fre-
num is transfixed at its base and divided from behind forwards, or whether
we simply cut from its free edge backwards towards its adhesions.
In every case it is better to separate it by paring the glans, so that no
OPERATIVE StJRGIiRY. 665
protuberances may continue on this part after the recovery. Its destruction
by caustics, such as the nitras argenti, as was formerly done and is still
among some surgeons, could only be advisable in a patient whose fear of a
cutting instrument was excessive. Although dressing of any kind is almost
unnecessary, if the individual be irritable or timid, we may cover the little
wound with a piece of linen spread with cerate and some lint. Care must
be taken not to allow the prepuce to remain too long in one place, if it con-
tinues to cover the glans; for thus the parts might become readherent, and
the object of the operation would be unattained.
§ 5. Adhesions of the Prepuce to the Glans,
The inner surface of the prepuce is sometimes closely adherent to the
glans, to a greater or less distance from the orifice. When no constriction
accompanies this affection, it does not usually bring with it any remarkable
inconvenience ; so that it would be imprudent to seek its removal by an
operation.
If it however impeded coition, of which examples are cited, and the per-
son was willing to be rid of it at any risk, the following plan is to be adopted
for curing it.
After having detached the prepuce below to an extent sufficient to allow
of its longitudinal section, the surgeon is to dissect off its whole circumfer-
ence, little by little, as far as the union of the glans with the body of the
penis. To prevent the surface from again coming in contact and adhering as
before, the skin must be kept drawn down towards the penis, and the wound
be covered with a perforated piece of linen, spread with ointment, and sus-
tained by lint, a compress, and a bandage : in short, every method is to be prac-
tised by which the two bleeding surfaces may separately be made to cicatrize.
It has been justly observed by J. L. Petit, that the separation of these surfaces
is neither easy nor unattended with pain. It would perhaps be best, when they
exist on the whole circumference of the glans, to let them alone unless they
are complicated with phymosis. On the other hand, when only a simple
frenum exists, or that only a portion of the organ is confined by them, the
facility of their destruction, and the curvature of the penis during erection
which results from them, induced us to separate them. It has been ably
shown by M. Langier, that in children in whom phymosis prevents us usually
from recognizing their existence, or at least discovering from their situation,
amputation of the prepuce or circumcision is the most rational measure to be
instituted, if after such an excision the greater part of the glans can remain
uncovered.
§ 6. Destruction of the Prepuce
Instead of being of too great a length, and adhering to the glans, the
prepuce may be too short, or have met with a loss of substance more or less
extensive. Celsus who had turned his attention to the mode of remedying
this defect in conformation, advises a circular division of the skin at some
distance from the glans on the body of the penis, and that then the integu-
ments be drawn forwards and fixed by sutures beyond the free extremity of
84
666 NEW ELEMENTS OF
the organ. We now know to a certainty, that such an operation is useless,
that the cicatrix invariably retracts the skin by degrees, so as to restore the
parts to their original condition ; but we might probably succeed better by
stripping the anterior part of the virile member of its integuments, for an
inch or two, so as to be able to bring them over in the form of an artificial
sheath, as far in front as the meatus urinarius, just as we raise up on the face
the soft parts removed from the neck in the cheiloplastic method of M. Roux ;
only we should then have to be watchful, lest the adhesions of the new
sheath should be prolonged on the surface of the glans. If the prepuce had
lost but a small portion of its contour, and the fissure could not be united by
the hare-lip operation, we should then have to dissect the two edges of the
division more or less off, then to approximate and reunite them afterwards by
sutures, after having irritated the edges. As .the prepuce is as susceptible of
being mended in all ways that can be adapted to nose or face, it is evident
that strictly speaking the posdeplastic has as many shades of application as
the cheiloplastic.
M. Dieffenback has proved that Sabatier, as well as Petit, was wrong in
rejecting as useless or impossible the various methods of restoration appli-
cable to the virile member.
§ 7. *dmputation of the Penis,
The mobility and extreme distensibility of the envelopes of tne penis is such,
that tumors, of the prepuce for example, gradually push back the glans and
corpora cavernosa, so as to appear to occupy the body of the member itself,
when in reality its appendages alone are affected. Hence doubtless arises
the error of many older writers, who believed in the reproducibility of the
penis, and who thought they had seen it spring forth again after amputation.
In fact a considerable extent of parts may be removed, without trenching on
the meatus urinarius. The tissues which had been turned back by the tumor,
or tumefaction, then lengthen again, and soon resume their primitive dimen-
sions, so as easily to impose on prejudiced minds. Cancer is not the only
disease capable of producing a similar illusion ; all other degenerations possess
this property. It even happens sometimes in cases of acute inflammation.
In 1824, there came a robust man, about forty years old, to the Hospital du
Perfectionnement, in whom the penis, highly inflamed as high as the pubis
and enormously swelled, sphacelated to within two inches of its root, in twenty-
four hours. Precautions were adopted for saving what remained of the glans,
or corpora cavernosa, in this putrid mass ; but they were found entire behind
the sphacelus, and with no other lesions than slight excoriations in front.
Amputation of the penis may be total or partial; total when the
cancer occupies its whole extent, and partial in a contrary case. Such cancers
as originate in the sldn, whether on the prepuce or elsewhere, are a very long
time generally in reaching the fibrous envelope or spongy tissue of the organ.
The extirpation of them is therefore to be begun in such away as to respect
the principal organ, and so as also to sacrifice it if found really morbid in struc-
ture. The precept of removing only degenerated tissues, on which so many
old authors have insisted, and to which Callisen so frequently recurs when
speaking of the operations to be performed on the genital organs, has been too
OPERATIVE SURGERY. 66^
often forgotten ; and we are indebted to M. Lisfranc, for the eflforts which he
has made in our time to recall it to the attention of surgeons. Besides the
peculiarities relating to the envelopes of the penis, its amputation requires
that the disposition of its proper constituents be not lost sight of. The fibrous
sheath which forms its envelope or shell, and the spongy tissue, whose cells ail
communicate with one another, dispose it to lengthen or retract immediately
after the operation, according as it was previously doubled back or drawn
forward by the cancerous tumor. The cavernous arteries, enclosed within it,
one on either side, having but little adhesion, project from the surface if the
wound of the stump retracts considerably, while if on the contrary it suffers
elongation they will appear to be deeply buried in its areola. The urethra,
at its under surface and in immediate contact with the skin, has this pecu-
liarity about it ; that owing to the junction of its upper and free to its under
ide flatwise, it is hidden on the circumference of the wound, immediately after
the amputation.
Tlie Operation.— ^By Ligature, The great dread of hemorrhage induced
some of the ancients not to use cutting instruments in the removal of the
penis, and to prefer its strangulation by ligature. Ruysch gives an example of
a successful application of this method. Heister, Bertrandi, and some other
surgeons of the last century did not disdain the employment of the same means.
In performing it, it would always be proper first to introduce a sound into
the bladder, in order to prevent closure of the urethra by the ligature. If it
is feared that application of the ligature upon the skin would be too painful,
there is no objection to following the advice of Sabatier, and making an
incision circularly into the integuments, and before putting on the thread :
but it is precisely this very incision, as painful as amputation itself, which
makes patients afraid of excision and leads them to prefer strangulation.
By Jlmputation. — The patient must lie horizontally on the edge of the
right side of the bed. An assistant takes hold of the root of the organ, and
draws tlie skin more or less towards the pubis, as it appears that the disease
has drawn it forwards to a greater or less extent. The surgeon then seizes
tiie tumor covered by a cloth, and holds it firmly in his left hand. With his
right hand, armed with a small scalpel or a bistoury, he makes one perpen-
dicular incision from above downwards or from below upwards, through the
body of the penis, a little beyond the limits of the disease. A previous
division of the skin, a little in advance of the spot where the corpora cavernosa
are to be cut through, would scarce lengthen the operation, and would
always allow the section of the penis to be even with that in the retracted
integuments.
This proceeding, recommended by M. Boyer when the disease extends to
the scrotum, seems to me in every case to merit the preference. There are
generally six or seven arteries to be tied ; viz. the two dorsal, the two caver-
nosus, the two superficiales perinei, below j then on the lower median line
those of the septum. However, the principal ones are the two dorsal and
two cavernosa. Should tying them be at all inconvenient, the laxity of the
tissue which surrounds the first would render their insulation and torsion
extremely easy. It is nearly the same with the second ; but it matters not, in
such a wound where no immediate union is to be attempted, whether torsion or
ligature be adopted.
668 NEW ELEMENTS OF
Modification of M. Barthelemy. — Before proceeding to apply the dressings,
a catheter must be passed into the urethra. Some authors having asserted
that it was at times difficult to find the orifice of the canal again at the
bottom of the wound, a young army surgeon, M. Barthelemy, conceived
the idea of introducing the catheter previous to the incision, and cutting it off
as' well as the penis, so that it might always be found in its natural situation.
This plan might either be adopted or not, indifferently, but that it is liable to
be attended with the slipping of the cut extremity of the catheter into the
bladder, besides rendering by its own section somewhat less easy the ampu-
tation of the penis. Moreover, it is clear, that for a man of any anatomical
knowledge, this search after the orifice of the urethra never can be very
embarrassins:. If the skin has been too much crowded backwards it will
spontaneously return and cover the wound, and thus offer, possibly, some
inconvenience. If on the other hand it has not been sufficiently pressed back,
it will be seen to retract towards the pubis, and leave uncovered the fibrous
envolope of the corpora cavernosa. As there exists no remedy against this
latter inconvenience, while in the former the superfluous integument can
always be cut off, it is better perhaps upon the whole to draw the integu-
ments more or less towards the pubis in an amputation of the penis.
If we are compelled by the disease to operate very close to the pelvis, there
is still no reason for preferring ligature to excision. The vessels here can
present no great difficulty, and the actual or potential cautery, as advised by so
many authors, is a last resource fully sufficient to put a stop to any hemor-
rhage which might occur.
The Dressing. — The catheter once fixed in the urethra, all that is necessary
is to apply a perforated Maltese cross, which has in it a hole to allow passage
to the sound over the wound. X<int compresses, two small and long com-
presses, a narrow bandage which keeps them on the remnant of the penis and
then goes once or twice round the pelvis, form the whole of the dressing,
unless we prefer as after the operation for phymosis to use a suspensory or
T bandage, on which is fastened a small bandage or two ends crossed over
the bleeding surface. The only object of the catheter in this case being to
give exit to the urine without touching the wound and preventing the closure
of the urethra, an objection may be made to its use, by stating that far from
being injurious the flow of urine over the suppurating surface is often very
advantageous. In proof of this it is alleged that urine was once used in
facilitating the progress of healing wounds. It has appeared to some, that if
expelled by the bladder, this fluid would prove sufficient to impede the closure
of the urethra, and that moreover the urethra being lined with a mucous mem-
brane it is unreasonable to fear its obliteration. I saw in 1823, a fact which
seems to give strength to this argument. M. Bongon removed the penis of
an old man for cancer; a catheter was introduced, and the dressing applied
secundum artem. But the man, a maniac and exceedingly intractable,
would on no account permit the least apparatus on the wound ; and on the
second removed it all with the catheter. I reapplied them several times but
could never make him understand that they were to be kept on : at length we
gave it up, but not without anxiety for the result. However, the wound healed
very regularly, and the urethra preserved as large a calibre as could have
been wished. The catheter then is not indispensable. As its presence is not
OPERATIVE SURGERY. 669
without its inconvenience, we might, even if we did not wholly dispense with
it, employ it only during the first few days, so as to prevent a^y imme-
diate adhesion, and quite towards the end of the case as Le Dran recom-
mends, to prevent secondary stricture.
I cannot close this subject without one observation, which is, that simple
though it be, amputation of the penis is nevertheless often followed by the
most disastrous consequences. Though the patients who are the subjects of
it get well very constantly in fifteen or twenty to thirty days, the larger
number are speedily tormented with the most wretched ideas, and fall into
melancholy from which nothing can arouse them. Some, to avoid it, fly to
self-destruction, while others, at the moment when it is least expected, sink
beneath the pressure of the moral affliction into the grave.
SECTION II.
Sexual Organs of the Female, *
Abscess, scirrhus, lupus, tumors, and cysts of every species, and the
varices seen on the labia majora, require to be treated and operated oa
according to the same rules as when on any other part of the body, and
here required no special mention. Amputation of the clitoris and removal of
the nymphae, are so seldom called for, as to need no separate description.
^rt. 1. — Imperforation of the Vulva.
The deficiency of an aperture in the vulva is sometimes a congenital
defect ; at others it is the result of other diseases of the part ; again, it is
owing to the existence of the hymen, which*, instead of a simple valve, is a
complete disc ; and again may be caused by adhesions contracted between the
different parts of the pudenda. It may be that the occlusion of the vagina
extends more or less into the pelvis, or even to the cervix uteri itself. In the
young girl, before menstruation, the affection in question can in no wise injure
her health ; and, but for the catamenial periods it would be no otherwise preju-
dicial to the adult woman than as impediment to coition. It is always judi-
cious, if a surgeon is called early to the case, not to wait until the age of puberty
for the performance of the operation; for if the operation be undertaken to
remedy difficulties caused by retention of the menstrual fluid, its consequences
are usually more serious than when done in infancy. If the vagina be closed
by a membrane only, it is sufficient to pass into it the point of a straight
bistoury, to incise it freely from before backwards, then across, and to excise
the four angles thus formed for its destruction. Afterwards its continuity is
to be preserved to a sufficient extent, by the assistance of pledgets of lint or
sponges of a teat shape. ^
If previous to marriage the use of these dilating measures were to be dis-
continued, there would be incurred the risk of a greater or less retraction or
of its entire reclosure ; of which the case of a little girl six years old, in whom
a colleague of mine only effected a longitudinal incision of the hymen, fur-
nishes me an example. It is perfectly useless first to puncture with a trocar,
and then to employ a director on which to guide the bistoury or any other
particular instrument. Having effected its perforation, forceps and flat
670 NEW ELEMENTS OF
curved scissors, or a common bistoury even, are sufficient always for removing
the portions of the membrane. It is not common to be called on to perform
this operation on any female of adult age, unless she have symptoms simulat-
ing those of pregnancy, such as enlarged abdomen, &c. owing to the retention
within of the menstrual fluid. If the hymen alone obstruct the passage, it
will be found arched, tense, and often of a bluish or blackish tint, from the
presence of the blood behind it and which is pressing it forwards. In that
case it is easier, even, to open than in the preceding one, and any one may do
it v/ithout danger. Only the sudden evacuation of so vast a quantity of fluid,
and the inability of the uterus and other distended organs to retract imme-
diately on themselves, give rise afterwards sometimes to visceral inflamma-
tion, and fevers of a bad type. Perhaps it is better to use no pressure or
means to hasten its expulsion, and to leave it to the natural contractility of the
organs in which it has been so lodged. Thus no vacuum is created in the
cavities into which we have opened. It is not possible for air to enter in and
stagnate, or react upon the morbific fluid or on the parietes of the cyst, and so
produce the mischief of which it is generally accused. Emollient, detergent,
or slightly resolvent, or even antiseptic injections are not to be neglected if
their use be indicated. As soon as fever, heat, and pain in the bottom of the
abdomen ensue, the patient is instantly to be put upon the severest regimen,
and antiph^ogistically treated with an energy proportioned to the violence of
tjie symptoms.
The operation is naturally rendered more difficult when the obliteration ex-
tends into the vagina to any distance from the external orifice ; first, because
it is impossible to say how far the portion obliterated extends, unless a sort of
diaphragm, a transverse perpendicular septum be the obstacle to be destroyed ;
secondly, and above all, we have to employ instruments between twoverv
important parts — the rectum and the bladder.
Before we begin then, let us be well assured, by introducing a sound into
the one, and one or two fingers into the other, that a certain thickness of tissues
exists between the two canals, that the uterus is in its normal situation ; lastly
that the vagina is not wholly obliterated, for if it were it would be almost
impossible, and consequently rash, to attempt its artificial re -establishment.
Still I believe, that if the life of the patient was threatened by the menstrual
accumulation, and that there existed the slightest chance of reaching the
uterus, by cutting away between the rectum and bladder, we ought to dismiss
every fear, and shrink not before the difficulty of the measure. Suppose it to be
thought advisable to resort to the operation. The woman is to be placed in
the position as in operating for stone. With the index finger of the left hand
in the rectum, an assistant keeping a female catheter in the bladder, the point
of which he raises towards the hypogastrium, the surgeon passes into the direc-
tion of the vagina either a long narrow bladed bistoury or an armed trocar.
The cessation of resistance, freedom of inclination given to the point of the
instrument in any direction, are evidences that it has entered the seat of the
affection. He then enlarges the wound a little in its whole length by with-
drawing the bistoury, whose cutting edge should be drawn backward, forwards,
and laterally, if he be sure of not cutting the neighboring organs.
When a trocar has been employed and the canula gives exit to a black and
viscid liquid, a director may perhaps be indispensable for enlarging sufficiently
OPERATIVE SURGERY. 671
the artificial canal we have made ; after which the introduction of the finger
will show if the division is large enough, or in what direction its further
extension is to be made. Although after such an operation the vagina generally
remains pervious, prudence requires that measures be taken to prevent its
closing. A tube, either of metal or simply of gumelastic, gradually augmented
in size to a certain point would be the best thing, I think, for accomplishing
the object, although pledgets of linen or lint, removed every day for the ad-
ministration of the injections might equally sufiice.
Scientific records contain so many cases of successful performance of similar
operations, that it is superfluous here to recite one in detail. MM. Ventura,
Cabaret, Delpech, Desgranges, Williams, Toulmouche of Rennes, &c., have
within a few years completely succeeded in several, and new ones are every
day laid before the public.
It must not however be forgotten, than in a case recorded by Morgagni,
the woman died in a few days ; and that on examination, the urinary bladder
was largely laid open, and one of the fallopian tubes burst into the abdomen
from dilatation by blood ; nor that M. Dupuytren has frequently seen it at-
tended mth fearful accidents.
Art, 2. — Puncture of the Uterus.
Closure of the Os Tincse. — As in the vagina there may never have been any
aperture to the nedc of the uterus, or it may have become closed by accident,
it is equally impossible for the menses to be expelled, and it is therefore liable
to the same consequences. The first thing to be done when we have decided
that an imperforate uterus really exists and is distended by a fluid, is to
seek, by means of the finger, for the neck in the place in which it ought to be
situated, and to try, if it be discovered, to overcome the obstacle if possible
by the introduction of an ordinary catheter. Otherwise its perforation
must be resolved on, which has now been done a great many times with
various instruments. Some advise the puncture to be made with a trocar,
others that it be made in preference with a straight bistoury covered to a few
lines of its point with a strip of linen, &c. The " pharyngotome" even has
its admirers. Dance tells us that Barre employed a long canula, armed with
a spear-shaped point, which had a fissure on its concavity ; so as altogether to
bear a strong resemblance to the " arrow headed sound" of Frere Come. On
this subject every one is at liberty to please his own taste and adopt the in-
strument he most admires. A rather long bistoury, concave, and protected
by lines, carried in on the index-finger of the left hand, will answer perfectly
well for every purpose, while every indication will be equally fulfilled by
using the *' sonde a dard," the trocar, or the " pharyngotome." Neverthe-
less, I believe the bistoury and trocar to be the preferable instruments. All
that is necessary is, to make an opening into the uterus large enough for the
fluid to escape from it, and not to venture too far either in the direction of
the bladder or rectum. As in the operation on the vagina, we must here
likewise guard against the return of the disease, and do all in our power to
prevent the newly established orifice from closing up unless the natural neck
of the uterus should be discovered. We must attempt, therefore, to convey
into the uterus the end of a gumelastic catheter, through which the fluids
672 NEW ELEMENTS OF
may flow while the wound is kept open. In the operation recently performed
with success bj M. Herves de Chegoin, he used a trocar, the canula of which
permitted him to carry up a bougie, which in its turn conveyed the end of a
gumelasti'c catheter, destined for continuing in the wound, and which Was at
a later period replaced by a female catheter. This is the wisest plan, and
one which all had better follow, be the instrument used a trocar, bistoury,
or what it may.
Retroversion. — Another species of disease may also require puncture of the
uterus ; I mean retroversion of it d^lring pregnancy. When the retroversion
is prolonged beyond the third or fourth month, it is sometimes impos-
sible to effect the replacing of the organ, owing to the constant increase
of volume of the displaced uterus. The only remedy then, which naturally
presents itself to the mind is the removal of what it contains. As that of the
child cannot be attempted, we have but to remove the water enclosed in the
membranes of the embryo. This very plan, originally advised by Hunter
in cases of retroversion, has already been practised many times with suc-
cess. Twenty years ago a case was related by M. Jaurel of Rouen, another
was witnessed at Lyons, under the inspection of MM. Viricel and Bouchet.
A third has been more recently recorded by Mr. Baynham, so that it is not as
formidable as had been imagined, and is a means of relief worth keeping
in reserve.
The woman being placed in the same position as in the preceding case, and
kept there by assistants, the surgeon examines on which side of the rectum
or vagina the uterus is most distended. One rule which it would be well, I
believe, never to infringe, is to begin by doing every thing possible to intro-
duce the instrument into the womb through the opening in the neck. Unless
absolutely impossible, puncture by the vagina seems to me less dangerous
than that through the rectum, inasmuch as we are not inevitably compelled
to perforate the peritoneum, and not as much exposed to come upon the pla-
cental mass. Mr. Baynham, however, did it in this latter method, probably
because the development of the uterus was in this direction much more
decided than in that of the vagina. I must own that the general use of tro-
cars leaves no fistulous openings either in the gut or uterus, and that the
wound closes up as soon almost as they are withdrawn. In Dr. Baynham's
case only two ounces of fluid escaped by the canula, which was nevertheless
sufficient to permit the reduction of the displacement. Abortion ensued at
the end of some days. The foetal envelopes were yet entire, and contained
still several ounces of water; the placenta had been pierced as well as the
abdomen of the child. In such a case the trocar should be longer than for
ordinary paracentesis, and somewhat curved. That contrived by Fleurant
for puncturing the bladder through the rectum would do very well. As it is
possible to entangle it in the placenta, or that the cord or foetus may close its
orifice, it is well to plunge it pretty deep, and to have a long stylet which may
be passed through the tube fo clear its upper end, and permit the fluids to
flow easily through. After the puncture, we must strive to restore the womb
to its natural position. But that abortion is an almost inevitable conse-
quence, the attentions afterwards to be paid would merely be those which
enter into the list of what are called for by pregnancy.
OPERATIVE SURGERY. 673
%^rt. 3, —^Prolapsus of the Vagina,
Instead of merely reducing the protrusion and being content to keep it up
by pessaries, M. DiefFenbach conceived the idea of applying to the pro-
lapsus of this organ, the same method of cure which had long before been
adopted by M. Dupuytren in that of the rectum. He first effects the return
of the part, then to prevent its reprotrusion he excises all around the vulvular
orifice, the loose folds on the inner surface of the labia majora, or perineum.
All tliis with a pair of good scissors and forceps is done without any difficulty.
The folds thus removed ought to constitute so many radii, having the vagina for
their centre, so as that their extremity may extend for an inch or half an inch
into it.
The dressing consists in merely washing the little wounds every day ; or if
we wish to obtain a smooth cicatrice and cause them to suppurate, in the
introduction of a pledget of lint rather bulky, whose base will easily furnish
a little bundle for each incision.
The object aimed at in this operation is to contract tlie vagina at its
entrance, and the vulva, by giving them a degree of firmness, which they had
long before ceased to possess. Although it has not failed to succeed, the plan of
Messrs. Heming and Marshall, which consists in the excision of a large elliptical
portion of the mucous membrane, and the immediate reunion of the wound by
suture would evidently not answer as well. We shall resume the explanation
of this subject when we reach the consideration of diseases of the rectum.
Should the prolapsus of the vagina be of very old date, and should the tissues
have undergone degeneration, or such change as to render its reduction totally
impossible, which appears to have been the case in the instance reported by
M. Berard, Jr., and the patient at the same time determined upon being
relieved from it, we have clearly no other resource to propose than excision.
Yet as unhappily it is difficult in these circumstances to say positively that tlje
prolapsus is of the vagina alone, and that the uterus is not comprised in the
tumor, in which case the danger attending would be extremely serious, it is as
Boyer has said, one which should never hastily be decided on. It should be
performed, as will be detailed in speaking of removing the uterus, either by a
cutting instrument or by ligature.
Art, 4. — Reduction of Prolapsed Uterus and Vagina,
Whether it be the vagina or uterus which presents at the vulva, or the
uterus shows itself in the neck, or reversed on itself as the finger of a glove ;
whether it be prolapsed a third, half, or all its length, or be reversed within
the pelvis, this operation, reduction, is aKvays to be employed ; replacement
always to be practised ; and some rules are necessary, of whose importance
the surgeon ought not to be unmindful. These displacements are accom-
panied sometimes with symptoms which should claim for a moment the
attention of the practitioner. Some must be encountered before the reduc-
tion can be proceeded with, others can scarcely be expected to disappear
until after it is effected. Among the first are fever, inflammation, and
general reaction; among the second, leucorrhoeal discharges, ulcers, and
excoriations. Pain in, and engorgement of the tumid organ, are no further
85
674 NEW ELEMENTS OF
obstacles, than as offering a true mechanical impediment to the restoration of
the parts. But for all these the best remedy, the best soother, nay the surest
antiphlogistic agent is reduction, when reduction can be accomplished. If
the vagina protrude, after its whole surface is enclosed in linen besmeared
with cerate, it is to be gently squeezed between the fingers, from the circum-
ference to the centre, befpre it is pushed from below upwards. An inverted
uterus requires a similar application of a piece of linen ; but it might be well to
apply the tips of the fingers to the most projecting part of the tumor, so as to
replace it more surely, and absolutely to carry it up above the superior strait
of the pelvis. When simple prolapsus uteri only is present, it is similarly to
be wrapped in linen, and as is done with the vagina, we must strive to lessen
the base, whilst we at the same time push it back by its summit in the
direction of the axes of the pelvis. Suppose there is retroversion. It is some-
times necessary to vary the patient's position, who may in the preceding cases
remain in the horizontal posture, with the limbs and muscles all relaxed. The
first thing to be done, to right the uterus thus retroverted in the pelvis,
is to hook with the index and middle fingers of one hand the os tincse,
usually arrested behind or above the pubis. This not answering, a finger or
two of the other hand are passed into the rectum, to push up and forward the
fundus, whilst we endeavor to draw down the neck at the same time. Failing
in these resources, we are advised next to place the woman on her elbows and
knees, so that the weight of the abdominal viscera may tend to force the
fundus uteri towards the umbilicus, whilst the surgeon is trying to unloose it
at the same time. If still foiled, we must imitate Dusaussois, who by the
introduction of his whole hand into the rectum vanquished difficulties which
until then had been invincible. If the finger had not hold enough upon the neck,
it would be proper, as is recommended by M. Bellangen, to introduce into
the bladder per urethra the flat sound of Segrot, or a similarly shaped
catheter, which might afterwards be used as a hook by turning its concavity
backwards.
It is not necessary to say that in simple displacement of the uterus within
the pelvis, and in any other case when practicable, we must begin by emptying
the bladder by the catheter, nor that it is sometimes easy to embrace the parts
to be returned with our fingers, sufficiently firm without using the piece of
linen. Repose, a horizontal posture, appropriate injections, venesection, and
a general antiphlogistic regimen, are for the most part proper after these
operations, as after most others, to moderate the irritation which must have
been produced, and to permit the tissues to resume their accustomed functions.
^rt, 5. — Pessaries,
The word pessary, which once comprehended every kind of material what-
ever which was introduced into the vagina to support the uterus, and prevent
it from becoming displaced, is now applied only to certain instruments
of definite shape. Hence we designate by different epithets, the bladder
introduced by Columella into the vagina of cows, a practise since him
imitated by some surgeons on the female, in the same manner; the folds of
linen and masses of tow, of which Moschion and Absyrtes speak.
Pessary of the Vagina, — Among the instruments now in use among us
1
OPERATIVE SURGERY. 675
t;ome whose end is to keep up reduced hernia of the intestines which have
descended behind the parietes of the vagina, or to prevent the descent of this
part itself. Others again are intended to obviate descent or displacement of
the matrix.
The former are of two kinds. The one a long hollow cylinder, about four
inches long, called **pessaire en bonden" (bung or stopple shaped), and of
diameter sufficient to fill the whole organ. The others, invented by M. Jules
Cloquet, are called *' elytroid pessaries," and differ from the preceding in
being a little flattened, concave on their front part, slightly swelled out at
each extremity, and having a very small canal or passage in the centre. The
name which the Professor has given them, would be more applicable to the
stopple -shaped pessary, since it means merely " of a sheath-like form ;" but the
name is of little consequence provided the mechanism be well understood.
The same steps are to be taken in the introduction of either instrument.
The woman lies upon her back, the thighs moderately flexed, and the legs held
a part. The pessary rubbed with cerate is carried by its small extremity to
, the orifice of the vagina, then introduced from below upwards, and from before
backwards, into the cavity of this organ.
The elytroid pessary being larger in one direction than in the other, is to
be presented flatwise to the large diameter of the vulva, and so that its pos-
terior angle may first enter the vaginal aperture, and serve to depress the
rectum and thickness of the perineum with some strength. The other angle
of the same extremity is then depressed gradually, slipping beneath the arch
of the pubis ; after which no further difficulty is experienced in the introduction
of the instrument into the vulvo-uterine passage. When once within it, it is
made to experience a rotatory movement, v/hich brings its convexity towards
the intestine (rectum,) its concavity forwards, the superior extremity beneath
the cervix uteri, and the inferior extremity, which is the largest, above and
crosswise between the ossa ischii. The "stopple-shaped" pessary, being
merely a tube with very thin sides, is generally introduced more easily : but
as it is straight and yeilding, its shape is soon spoiled by the organs, and it is
not long before it becomes useless.
Pessary of the Uterus. — Pessaries of the second kind have experienced
many more variations in form and materials than those of which I have just
spoken. The ancients constmcted them from an oval or elliptical plate of
wood or cork, which was covered with a coat of wax of unequal thickness ;
besides which they were of gold, silver, copper, lead, and even tin, of every
shape. Those called ** ring-shaped" (en gimblette) were either entirely cir-
cular or slightly curved before and behind in the form of a figure of 8, or else
depressed at the four extremities of their'two principal diameters together;
or simply ellipsoid, flat, and pe^-forated in the centre. In England, a globe-
shaped pessary is employed, sometimes hollow, sometimes solid, pierced in
the centre or not, and the same method is adopted in America. Cork and
wax have been long entirely rejected as too easily altered by the pressure of
the parts, and not sufficiently supple. The same fault may be found with
ebony, ivory, gold, silver, singly employed, especially as we possess materials
so much more elastic, lighter, and less changeable. They are now made almost
altogether of elastic gum ; though sometimes it is supported qn linen, horse hair,
felt, woollen, silk, &c.
k
676 NEW ELEMENTS OF
In order to have them as light as possible, M. Rondet, who employs a well
tempered steel ring covered with horse hair, and real caoutchouc, has con-
trived others of the same substance, the circle of which is hollow and filled with
air. As bj the use of this composition pessaries continue elastic, and rather
flexible, causing but little irritation of the parts, and are much less easily
altered in shape than most others, they justly deserve the preference which
they usually receive. Dr. Physick however still continues to use gold and
silver pessaries, which are globular, as in the times of Clark and Denman,
and consist of two capsules soldered together at their base.
Those pessaries which are rather broader transversly than from before
backwards, are in the whole most easy of introduction, and least apt to inter-
fere with the functions of the bladder and rectum. They are more easily
inserted even than the vaginal pessaries. All that is to be done is to carry
them into this passage with the same precautions which are indicated above.
The finger placed within the ring, or some point of their circumference,
permits us to give them always a suitable situation ; that is, to effect a see-saw
motion which brings them horizontally within the pelvis, one edge before, the
other behind, and the extremities towards the ischii, so that the os tincae
may rest on the superior concavity which extends through all their thickness.
Women who have lascerations of the perineum, or in whom the vulvular
orifice of the vagina is very large, derive scarcely any benefit at all from the
<*pessaire en gimblette" or from the ball-shaped, which they can seldom
retain. Surgeons were therefore early obliged to resort to other more perfect
instruments to supersede them. The species described by Bauhin as " en bilbo-
qufit" (cup and ball), are made of a ring of ivory or wood, which is supported
by three branches ending in a long stem, several inches in length, and having
three or four holes at its free extremity. The cup of this instrument, intended
for the reception of the neck of the uterus, is deep enough to allow an easy
escape, between the three branches of the stem, for the menses and other fluids
which come from the uterine cavity. The ribands which go from the lower
apertures of the stem are to be attached to a girdle, which the woman is not
to leave off.
Desormeaux having observed that, notwithstanding the grooves between the
cup of the pessary and its root, fluids sometimes accumulated about the neck,
and these acquired irritating properties, contrived to convert the stem, of the
instrument into a true canal, and to give the cup the shape of a very small
and shallow funnel ; but in spite of his precautions the fluids still collect
sometimes between the uterine orifice and the instrument which supports it,
so that in fact it is of no great importance to prefer this pessary to the old
one. If as some practitioners, Desormeaux among others, insist, we did but
fix the olive-shap*>d extremity above the coccyx within the vagina, rather
than tie it with ribands to a bandage around the body, there would be so much
risk of perforating the rectum that I could not recommend its adoption ;
even though the instrument should be fitted with the peculiar spring within
the pivot recommended by M.Recamier. Some, with the idea of guarding
against the vacillation and unsteadiness to which the instrument as the woman
walks is perpetually subjected, have advised the use of pessaries which have
at the lower end a plate about four inches long, concave above, and pierced
with a large hole behind, opposite the anus, and with two slits in front so
OPERATIVE SURGERY. 677
that strings attached to the four angles of this plate allowed them to embrace
the whole extent of the perineum closely from before backwards, and to
keep the pessary nearly immovable in the direction which has been given
to it.
Saviard, discontented with the pessaries in use until his time, invented a
little apparatus of extreme ingenuity, for supporting the uterus, consisting of
a curved spring fixed by one extremity on the hypogastrium, whilst the other
entere'd the vagina to compress a tampon conveniently adapted to it. That
proposed by M. Villerme is upon a similar principle. Its stem represents a
large arch, the concavity of which, when it is introduced, ought to embrace
the anterior half of the pelvis. It is a sort of hook, the tail of which fastened
upon the hypogastrium permits the head in the vagina to sustain or support the
whole gestative organ. M. Deleau has just brought forward another, which
holds a sort of middle place between the'* round" and " cup and ball" pessary.
It consists of an elastic spring surrounded with gumelastic, twisted into spiral
curves of which the apex or first ring is fastened, and the b^sis or last ring
hangs loose, to be tightened or widened according to need. When it is wished
to introduce it, the circle is sufficiently narrowed, and a sort of piston is
fastened to its head. Left in the vagina point uppermost, its elasticity
readily adapts itself to the dimensions of the part, without any risk of being
displaced. In the collection of theses by Haller, Preuner describes one similar
in almost every respect, and I much fear that its advantages are more apparent
than real. Whatever be the pessary employed, care must be taken to with-
draw and clear it from time to time. Otherwise it might become covered with
calcareous matter, create ulceration of the vagina, and give rise to serious
consequences, of which many instances are recorded. Women soon learn to
perform this little operation for themselves, and to have no need of any one's
assistance to replace it at proper seasons. When first introduced it is useful
to keep the patient for some days in bed : otherwise she would be exposed to
more or less suffering from a sense of weight about the fundament, which is apt
to excite symptoms of irritation, much less liable to happen when time has been
given to the parts to become accustomed to the foreign body, and as it were to
mould themselves upon it.
One question here presents itself, which must be answered ; are pessaries
really advantageous ? no doubt they do give a great deal of trouble and incon-
venience, and create many accidents. Many women undoubtedly cannot en-
dure them at all.
The pressure they cause upon the bladder and rectum, necessarily is an
obstacle to the function of these organs. The neck of the uterus more or less
irritated by such a body, enters and is strictured within the aperture of the
pessary which in turn is too apt to end by excoriating and perforating the walls
of the vagina, if not of the rectum, or bladder of urine. If instead of the round
pessary the cup and ball instrument be preferred, do what you will with
it, it will lean more in one direction than in another, and will at length
depress the os tincse as well as the vagina. The round one almost always
turns over backward or forward, and equally ill supports the neck of the
uterus. As to the " stopple-shaped" pessary, owing to the thinness arid
almost cutting character of the openings at each extremity, it also easily
injures the parts on which they are applied. The " elytroid" pessary yet
678 NEW ELEMENTS OF
remains, which as it is moulded on the canal, and fills it with some
accuracy, is less liable to be displaced, preserves the parts in a natural
position with greater certainty, requires fewer precautions for its proper
management, and hence offers fewer objections than any other. But as
it is a larger mass and fills the whole organ, many women find it in
this respect very inconvenient. Still it is the one which appears to me
to deserve the preference, and that which I employ when I cannot dispense
with a pessary of some kind. Since these instruments are so far from being
inoffensive why continue to use them ? Certainly in many cases in which they
are directed they ought to be proscribed ; for example, after simple prolapsus,
after the reduction of a retroversion, the introduction of oval pledgets of lint,
or of little bags, rendered astringent by being steeped in wine in which rose-
leaves, oxy crate, (vinegar and water) have been boiled ; of decoctions of kino ; of
solutions of alumen sulph. introduced and renewed every day within the
vagina for a long time, would be better than the use of pessaries. Fine
pieces of sponge, or of linen, arranged "and sustained as is done by women
during their catemenial periods, would also supersede them very advantage-
ously, if a mechanical means were absolutely necessary to keep up the uterus.
Thirdly, if the descent of the organ were evidently brought about by the
undue size of the vulva, the excision of its surrounding cutaneous folds,
though painful, would deserve I think the preference, as likely not only to
produce a permanent cure but also to permit the continuation of conjugal
enjoyment.
Art, 6. — Foreign bodies.
1. In the Vagina. — Those which we are occasionally called on to remove
from this part of the body are usually pessaries, or remains of pessaries more
or less changed in their nature. However, other substances also have been
observed. M. Dupuytren detected in it a pomatum pot, the bowl of which
was turned downwards. It is easy to fancy the variety in form and nature
which such substances as are introduced into the part by accident or design
on the part of the woman will present, and the character of the affection to which
they give origin. Pessaries which had been lost for ten, fifteen, and even
twenty and forty years, have been known to become encrusted with calcere-
ous matter, corroded, even perforated by fungous growths, to produce pain, in-
flammation, and the most fearful train of symptoms. In a woman cured by
M. J. Cloquet, the changes in the vagina was such as that until then it had
been considered as cancer. Usually they ulcerate and perforate either the
bladder or rectum, and sometimes both together. A woman broke the stem of
a •' cup and ball " pessary in attempting to withdraw it, and at length forgot the
ring in the vagina. After a lapse of many years, she became afilicted with
symptoms which induced her to seek the extraction of the foreign body. M.
Dupuytren then ascertained that it projected both into the rectum and bladder.
Another fact still more curious has also been published by M. Berard of which I
was myself a witness. The patient, an aged woman, had not thought of her
pessary for five and twenty years since she had broken the stem. By the ca-
theter it could be felt naked in the bladder, and very distinctly in the rectum
with the finger. The vagina below was nearly obliterated and consisted only
OPERATIVE SURGERY. 679
of a cul-de-sac, having a slight opening at its upper part. In the case which
was communicated by M. Larrouche to M. Jules Cloquet, the pessary
(which had a stem) had entered the rectum, where its cup had become the
centre of a stercoral calculus, while the extremity of the stem had done the
same in the bladder.
The operation called for under such circumstances must be as various as
the cases in which they are required, and cannot be restricted to the rules of
a particular description. If the pessary be unadherent, and we wish only to
put an end to the irritation which it causes, the index finger passed within its
circumference or on its edge will suffice frequently for its extraction. If it
be otherwise, a long polypus forceps might advantageously take the place of
the finger, or a soft blunt hook, carried in and protected by the index finger
of the left hand, may be tried. When it enters the rectum and cannot be got
out by the vagina it is to be drawn forth by similar means through the anus.
If its size offers an obstacle to success in this way, its division into pieces
may become necessary. If it be of wood, ivory, or any fragile material, this
is easily enough done by a strong and solid pair of pincers or forceps. We
cannot say so much for metallic pessaries. Here we must trust to the feeble
aid of a file or small saw carried up the rectum, and by a proper canula pre-
vented from injuring it; whil-t with forceps the foreign body is to be kept as
motionless as possible. M. Dupuytren succeeded in his object in the case
just related by means of a saw. In the patient whose case I witnessed at La
Pitie, M. Lisfranc began by making an incision in front of the anus, through
a portion of the perineum, in order to make himself more room. He then
seized the pessary without any very great difficulty, and promptly withdrew
it with the assistance of forceps held in the right hand, while the middle and
index fingers of the left hand directed their motions at the bottom of the parts.
The position of the woman, and the precautions necessary before and after the
operation, are the same as those directed in the other proceedings on which we
have dilated in the preceding sections. If a glass, a vessel either of wood or
earthenware, be the cause of difficulty, it must, when every effort to place it
in a favorable direction and so remove it entire has been tried, be broken in
pieces and removed piece-meal. The judgment of the surgeon must more-
over, make up for the silence to which books are necessarily reduced on such
sutyects. Unless the rectum or bladder of urine have been opened, the results
of the operation are very simple. It is likewise remarkable that the fistula in
them are not long in closing considerably, and even end by healing up en-
tirely.
Art, 7. — Foreign Bodies in the Uterus,
The cavity of the uterus sometimes contains free and inorganic masses,
wnich have been described by Louis, under the name of calculi of the uterus.
These calculi, which are thought by MM. Roux and Dupuytren to be altered
states of fibrous tumors, have often been observed. I have myself seen them
both in the cavity of the organ and in its walls. Whether the opinion of ;
MM. Roux and Dupuytren be or be not well founded, it is at least certain
that in a good many of the bodies of which I speak, are either simple, earthy
concretions, or the detritus of pregnancy. One which I had an opportunity of «
680 NEW ELEMENTS OF
examining, was as large as an egg, round and knobbed, contained in many
points of its circumference hairs, and some portions of osseous cutaneous
tissues, whilst its outer surface was but a calcareous crust. Thej have ,
awakened naturally the anxiety of surgeons, as capable of leading to bad
consequences. Hippocrates mentions an old woman who had taken one from
the vagina of a servant, ^tius advises that they should be made to pass the
neck by pushing them downwards, with two fingers in the rectum and the
other hand placed on the hypogastrium; and then be sought for with forceps..
He likewise practised dilatation and incision of the cervix. Louis recommends
that cutting scissors be introduced into the os tincae, to open its orifice from
within outwards, and thus favor the exit of the calculus. To this there is but
one objection ; viz. that we never know that the woman's symptoms indicate
this more than any other uterine affection. As it is strictly impossible to be
certain on this head, no one at this day would dare to attempt the operation
of iEtius, still less of Louis, unless the stone were more or less 'engaged iji.
the cervix uteri and could then be distinctly felt.
Art, 8. — Polypi of tlie Uterus.
•No method of treatment has been proposed for the cure of polypi in general,
and particularly for that of nasal polypi, which has not been applied to this
disease when existing in the uterus. The latter species, from being situated
in a more accessible organ, one more easily explored, and more readily made
to change its situation, have not excited the ingenuity and genius, of surgeons
on this account as much as the others. Thus cauterization, of which Celsus
seems to speak, and which is alluded to by Verduc, Volter, &c. ; scarification ;
the use of dessicative remedies contained in the list of iEtius, and the book
ofMoschion have long been abandoned. On the other hand, simply tearing
them out, or this combined with twisting or torsion, is applicable only in a
small number of cases. The reason why it appears to Sabatier and other
modern authors that the treatment of this disease was much neglected by the
ancients, is, that it was known in medical books until a still recent period
under a great variety of different names. Philoteus, for instance, evidently
confounded them with cancer, and Moschion with varix of the uterus. There
can be no doubt on the subject, when the mysterious Aspasia describes them
as *' hemorrhoidal -tumors," which spring ** sometimes from the neck, some-
times from the fundus uteri," and «* seldom" from the external genital
organs; tumors which may be fearlessly excised when white and hard,
which *'must be tied," when they are easily excited to hemorrhage, and
which sometimes resist every means to remove them.
I understand the relative value of the various methods of operating for
uterine polypi ; and to reconcile the conflicting statements of writers on the
subject, a few words- as to their nature and origin become indispensable. It
is indisputable that tumors arise in the uterus perfectly different in character
from one another. The little polypus, noticed by Z. Lusitanus, the removal
of which was attended with so abundant a hemorrhage, may be compared to
the vascular polypus, so tenacious of vitality, seen soften in the nasal fossa.
M. Berard has seen in the neck of the uterus, soft, and nearly wholly mucous
polypi, much resembling those of the nose. I have thrice seen in the uteri of
OPERATIVE SURGERV||jj * 'W^if' ^^^
women, who were subjects for dissection in the practical scliool of anatomy,
tubercles of various size, containing small vessels which were continuous
with the tissues of the organ and yet not pedunculated. MM. Dance,
Berard, and Cruveilhier, have, with MM. Mayer and*Meisner, seen others
which appeared to be the result of true partial hypertrophy, either of the body
or cervix of the uterus ; that is to say, they were continuous with the fibres
of the viscus without any line of separation, and their structure was in no
respect diflferent from that of the viscus itself. In 1825 I published a case
of this kind, and preserved the pathological specimen in alcohol.
Others again, which are likewise continuous with the tissue of the uterus,
are evidently degenerations or morbid alterations of its structure. They are
hard, grey, and elastic ; when cut into their aspect is that of a lard-like or
semi-cartilagenous substance, homogeneous, white, wholly destitute of ves-
sels, and in which it is impossible to detect the least vestige of fibres. I
had occasion, in the beginning of this year, to remove one which possessed
these characters in a striking degree. The most numerous by far, are those,
nevertheless, which since the investigations of Bayle, Roux, and Dupuytren,
go by the name of " fibrous bodies," and are primarily developed between
the tissues in the thickness of the uterus itself. I am induced from som^
observation, to think that they often result from an effusion of blood, a.
fibrinous concretion, which becoming organized by degrees continues to sus-
tain its vitality, and to grow by imbibition in the midst of the surrounding
parts of a greyish or whitish color, like the preceding species, and always
appearing to be composed of fibres which interlace in different directions :
they contain no vessels, and are covered by a sheath from the uterus, thin in
proportion to the magnitude of the tumor, and which becomes more distinct
as we approach their peduncle.
This brief detail sufficiently shows that hemorrhage is to be apprehended
only after the removal of uterine polypi of the first varieties ; and that that of
the tw^o latter species can never occasion it. Now, as these are much more
frequently occurring it follows, cseteris paribus, that excision must be much
less dangerous than it was for a long time, and by some is still thought to be.
We must also be heedful before proceeding to an operation, that we have
not confounded the polypus with inversion or prolapsus of the uterus or vagina,
or with that elongation of the neck from hypertrophy spoken of by Lallement
and Bichat, or with cancer, &c. It is enough to point out the possibility of
these mistakes to prevent the practitioner from falling into them ; although
they have often been made, as well as errors of the opposite kind. There is
yet another which I never saw mentioned, and into which I was myself very
near getting. A woman, thirty-two years of age, came under my care at the
Hospital St. Antoine, in 1828, duri.ng my attendance there. She had from
time to time for a month past experienced slight losses of blood. On examina-
tion I discovered a mass as large as a small egg, a little swelled, of firm con-
sistence, and which extended by a very distinct peduncle to the upper part
of the neck. I took it for a polypus. The patient was placed in a bath, and
for three days prepared for the operation. When I carried my finger into the
parts I again encountered the mass I had before felt, but as I tried to follow
up the peduncle, it fell into the vagina and I removed it. It was a fibrinous
concretion, a mere clot of hardened blood ! Polvpi mav, in turn, be mistaken
86
t)82 ^ NEW ELEMENTS OF
for tumors of another kind. In 1823, MM. Richerand and Jules Cloquet
removed one as large as a child's head, which they took from the vulva of a
woman where it had hung for many years, and supposed they had removed
the uterus. The mass, which was opened in the presence of M. Richerand,
had a cavity in the centre, and almost every other character of the uterus;
and it was supposed to be an unanswerable demonstration of the possibility
of removing that organ.
The patient died. When examined, the uterus was entire in its natural
position ; an enormous polypus only had been removed !
. A woman from the country, who came to the Hospital Perfectionnement,
in 1824, to have what she called her " falling down" reduced, had in the
vulva a conical tumor, with a small transverse slit across its summit, which
she had for a long time kept up by a pessary, and which I easily returned into
the vagina, and maintained there by a cup and ball pessary. After her return
home some days, she was attacked with abdominal pain and returned to the
hospital, where she died next day of peritonitis. The tumor which I had
reduced was a polypus, fastened to the fundus uteri by a peduncle as thick
as my finger !
1st Method. — Tearing forth. When fibrous polypi have effected an exit
through the neck of the uterus, they undergo a kind of strangulation, which
hs sometimes sufficient to effect their separation. Two examples seen by
Mercadier and Louis, have been reported by Levret. Similar ones had been
related by Mauriceau, Ruysch, Hoffmann, and before them by Rhodion and
M. Donatus, Vacoussin, Gooch, M. Hue, and more recently by M. Herves de
Chegoin, have also published cases. It has happened to me to se*e one yield
abruptly to the slight efforts I made to bring it towards the vulva to excise it.
Latterly Mr. Griffith has announced a like result by the use of ergot. Doubt-
less this falling of the polypi led to the idea of the plan of tearing them out as
practised by Dionis, Juncker, Heister, and since formally proposed by La-
peyronie, and afterwards by Boudou. These authors advise, at the same time,
torsion of the peduncle, whether as a guard against hemorrhage or to break
it more easily. Torsion, however, added to mere traction, may become dan-
gerous by extending into the tissues of the uterus. In 1753, Hevin sustained
a thesis in the schools of surgery, in which he maintained that by grasping the
origin of the tumor at its upper part, and turning it in itself with forceps, this
danger would no longer be incurred.
To perform this operation by laceration, we are to seize the body of the
polypus with the forceps invented by Musieux, or tlie ordinary kind, or even
with the fingers if small, or else with straight or curved forceps. We then
exert methodical traction, either simple or combined with slight rotary move-
ment, until it be drawn forth.
It is only at this precise period that the precautionary advice given by
Hevin can be followed; and the torsion, really such, advised by Boudou be
practised without inconvenience, in cases of thick foot stalks ; otherwise it
can have no good end, for if we are then afraid of immediate excision nothing
is easier than to apply a ligature on the narrowest spot of the morbid mass
and cut below it. M. Recamier, who thinks that these bodies can be des-
troyed, not only by extraction but by a kind of trituration or bruising, has
juiit published two remarkable cases in support of his assertion. In one, the
OPERATIVE SURGERY, 683
polypus as large as the great toe, projected into the vagina from its origin in
the upper part of the cervix uteri. By strong pressure with the index finger
of the right hand, he contrived to divide it, reduce it to a pulp, and extract it
in less than two minutes. In the other case, having resisted ligature and
extraction, it was futilously broken up by hooked forceps and the fingers into a
sort of flux, the filaments of which slipped ceaselessly through the teeth of
the instrument.
Method 2d. — Ligature. This treatment of uterine polypus is much more
ancient than Levret has supposed. It is evident that ^tius, Moschion, and
before them Philoteus, were acquainted with it, and that it was frequently
resorted to after their time. It is, however, but just to Levret to confess,
that it is to him we owe its adoption into the practice of modern times, by
showing its applicability not only to tumors which protrude from the vulva,
but to those also which are attached highest in the genital cavity.
To eifect it, many instruments have been invented. All those which are
employed for tying nasal polypi, may he used for this purpose. The two
tubes fastened together like forceps, the principal of which is so highly praised
by Levret ; those constructed by Theden on nearly the same principle and
plan ; the instrument of Lecat, and that of Herbiniaux, are now abandoned.
Neither has the use of the double canula of the first of these authors been
retained in practice. They have been forgotten since the separated hollow
tubes constructed by Desault, and the catheters of Niessen ; and every thing
leads to the belief that the alterations proposed by Clark, Laugier, Locffler,
CuUerier, and a crowd of others mentioned in the Treatise written by M.
Meisner, will speedily undergo a similar fate.
Method of Operating. — The instruments which have been judged advisable
being at hand, the operation is conducted in the following way. The surgeon
having reconnoitered the position of the polypus, and calculated the size of
its peduncle, arranges the ligature which he means to employ. This, which
in the time of Levret was of fine silver, is now more generally made of silk
or thread of the utmost tenacity. If the two canula of Levret are selected,
it is so placed as to make a handle on one side, and to be fixed on the other
side upon a ring which is placed outside of the mouth or aperture in each. One
or two fingers of the left hand, carried as high up as possible, convey the
whole to the pedicle of the polypus. The surgeon then takes one canula in
each hand ; holds firmly fixed in one spot that which has attached to its base
the ligature, with the other encircles the base of the peduncle until he can
cross them ; twists them ; then turns them together on their axis ; withdraws
them ; then includes the two conjoined extremities of the ligature in another
tube called a "serre-noeud" (knot-tightener), which allows of his strangulating
the tissues with all necessary strength.
The instruments of M. Desault, differ from those of M. Levret in having
two free and separate '* porte-noeuds" like those of David, and in one of
them a sort of forceps is enclosed, which when shut ends in a little ring at
the top. One half of the ligature is first passed into the plain canula, and
fixed upon the ring below ; the other is then laid hold of by the forceps, which
is closed and drawn back into its sheath, and which is notched at its inferior
extremity for the reception of the end of the second thread. This apparatus
is carried, like the former, by the fingers to the spot which offers the least
L
684 NEW ELEMENTS OF
resistance. When he arrives at th-e peduncle, the operator with his left hand
keeps the plain canula motionless, with the right seizes that armed with the
forceps, passes over with it the whole circumference of the tumor, and brings
it back to the level of the other, so that the ligature forms a complete circle
around the pedicle to be strictured. The split shank pushed into the canula,
opens by its own spring, loosens the string, and may be removed without its
being displaced. The extremities of the ligature being then united so as to
form but once piece, are then brought through an opening in a last piece of
metal, some inches long, the head of which has a hole in it, and is bent at
nearly a right angle on the body of the instrument. This '^ serre-noeud"
allows the elevation of the constriction to any degree of severity which may
be desired, and of its augmentation or diminution as may be seen fit. It is
finally to be fixed, after having been surrounded by linen, to one side of the
vulva by a small riband.
The apparatus of M. Neissen consists of two long silver canula, curved,
but sufficiently flexible to be straightened or bent, which serve to convey the
ligature. When they have arrived around the tumor they are both included
.in a third canula, divided by a middle septum into two tubes, and only one
or two inches in length. This, which seems but a fragment of the double
tubed instrument of Levret, is carried up from below with the fingers as far
as possible, and still higher by means of a hooked sound. It is intended to
increase the strangulation of the peduncle of the tumor more and more by
compelling the upper extremities of the two first canula to approach one
another strongly, without departing from theii" parallel direction.
At first sight no very great advantange seems to arise from these instru-
ments over those employed by the French practitioners. , The canula of the
German author, being no more than those of Levret a little increased in
length and curve, perhaps are better adapted for penetrating a great depth;
but I think the double tube intended to approximate them infinitely less cal-
culated for the object than the " serre-nocud" of Desault. If this latter portion
of the apparatus be thought to be in need of some alteration, the fillet, of
which M. Mayor has made so happy an application within the last few years,
would here, better than in the nose, deserve a justifiable preference. If, in
strangulating the polypus, we possessed neither the mechanical cylinder of
this author, nor the little instrument of the same kiftd invented by Levannier
of Cherbourg, we might simply attach the two ends of the ligature to a piece
of linen, or other solid body, and tighten them on that. The " serre-noeud
brise," which Bichat has endeavored to substitute for the forceps canula of
Desault, fulfilling very seldom the intention of its inventor, it does not seem
to me to deserve more than this notice. Nor do I think the speculum of *M.
Guillon, modified by M. P. Dubois so as to hold a ligature, of such a nature
as to supersede the very simple and ingenious contrivance of the veteran
surgeon to the Hotel Dieu.
When the ligature has been well applied, circulation and vitality are
quickly interrupted in every part of the tumor beneath it. Whilst this mass
is mortifying and being decomposed the ligature is gradually cutting through
its peduncle. It is easy to comprehend how this will be accomplished with
greater or less rapidity, according to the power of the constriction employed,
and to the density, resistance, and bulk of the tissues which it encircles.
i
OPERATIVE SURGERY. 685
Did the dimensions of the foot-stalk not exceed an inch in thickness, a single
riband drawn tight upon it would suffice to cut it through in some days.
Beyond this thickness it has been thought it would be better to transj&x it
with a needle and double ligature, so as to strangulate each half separately.
To this proceeding two objections may be made : 1st, polypi, which can be
drawn down into the vagina, the only ones capable of this transfixion, seldom
have root enough to demand such a precaution : 2d, those whose foot-stalks
are more voluminous, as to allow their being drawn down or not, are all
either fibrous bodies which ought to be cut off" by the knife, or morbid growths
which should be let alone altogether.
Between simple ligature or excision then our choice should lie. Among
the instruments for applying ligatures, that which M. Mayor has recently
proposed and figured in his treatise on "ligature in the mass," seems to me
especially worthy of a trial. It is composed of two elastic stems of steel or
whalebone, unless there were time to procure metallic ones, ending superiorly
by crab-claws. The ligature is placed in them just as in the instrument of
Desault, and is to be carried round the polypus with the same precautions.
To throw it off, we have only to pull rather strongly on the conducting instru-
ment, as soon as the knot-tightener arrives at the penduncle to be incar-
cerated. In the double tube of Levret the two portions of the string come
together too near the polypus to render their passage easy when we wish to
increase the constriction. It is so indeed with all "serrenoeuds," as I have again
recently experienced. M. G. Pelletan, who had like others suffered from the
inconvenience, had constructed by M. Sirhenry a very ingenious little apparatus
to do it away. The two branches of his knot-press which terminate its deep
end, separate slightly outwards, like a fork, for some lines superiorly, and are
applied by their sinus to the root of the polypus, and scarcely bend the liga-
ture, while they in some measure continue its circle. A spring, a kind of steel
fillet, curved in several direction to increase its elasticity, placed at the free
extremity of the instrument, receives the other end of the string and con-
stantly increases its tightness. This elastic part can be adapted to any other
instrument, and among others that of M. Mayor. The forking out of the knot-
press would only give trouble if it were to be turned on its axis to twist the
thread.
Bemarks. — Before we strangulate a polypus which is dependant without, it
behooves us to observe that its peduncle may proceed from the fundus of the
inverted uterus, and that in that case it would be dangerous to place the liga-
ture too high up on the tumor. Decomposition of a polypus within the sexual
organs often gives rise to accidents which we would fain avoid. The disgust-
ing smell too which attends it is so extremely nauseous to the patient and
those about her. When the polypus is large, and the weather warm, it really
becomes perfectly insupportable. The putrifying mass, moreover, may irritate
the vulva and vagina, and if it be reabsorbed may give rise to constitutional
infection, and a fever of a very bad type.
If the tumor cannot be drawn out we must resort, to overcome these inconve-
niences, to the ordinary methods of cleanliness, simple injections of mallow tea,
or barley water sweetened with honey, of decoctions of kino, or better still of
the alkaline chlorides in solution. But when the first stalk is naturally low
down, and may be brought lower still by moderate traction with but little pain.
686 NEW ELEMENTS OF
it is more expeditious, and certainly less dangerous, to cut off the whole mass
below a ligature than to leave it to come off of itself. It is not worth while
to discuss the question, which has been done by many authors of imposing re-
putation, whether when the ligature is applied to the parts before our eyes, it
is better to practice excision immediately than to wait for the mortification
produced by the ligature. By the former method the patient is at once
relieved, and that without any reasonable apprehension as to hemorrhage ; by
the second we do not guard against this unpleasant occurrence, and as it
exposes her to risk of the consequences without corresponding advantages on
this head, I think it ought to be abandoned entirely. Levret maintained that
after ligature mortification progressed to the junction of the polypus and ma-
trix, notwithstanding the constriction have been performed below this point ;
and that once strangulated, these tumors gradually separate always in the
same spot, nearly as does the umbilical cord at birth whatever be the spot
where the string had been placed. To M. Boyer, this seems a dangerous
doctrine. In fact were it false it might lead to vexatious practical results. If
it be adopted it would matter little whether the string be placed exactly orj
the upper part of the pedicle, or somewhat below it. As it is usually more easy to
place a ligature low down than high up, as likewise some may dread including
some part of the uterus tissue in it by elevating it much, the ligature
would often be so placed as to leave a part of the polypus still within
the organ. On the other hand, the statement of M. Boyer is correct,
that as life ceases in the tumor only as far as the constricting agent, the
ligature ought if we would guard against a return of the disease, to be
placed as high up as possible on the morbid growth. The opinion of Levret is
based upon facts. A distinguished surgeon in one of the departments, M.
Genson at Lyons, has quite recently supported it by a statement of his observa-
tions. It asserts neither any thing contrary to what is known of the laws of
the organism, nor which cannot be said of the separation of the umbilical cord.
It is essential that this point be well understood — ^mucous polypi, and those
polypi to which many vessels are distributed, and which are evidently con-
tinuous with the tissues of the uterus, do not probably make in favor of the
theory of Levret, which seems to me applicable only to those which are really
foreign bodies within the cavity of the organs, and to those polypi which
are purely lardaceous or fibrous, and destitute of any appreciable vascular
supply.
Sd. Excision. — More daring than were surgeons in the last century, the
ancients often performed exsection of genital polypi. Philoteus, ^tius, Mos-
chion, and others, evidently described this method when they advise that vari-
cose excrescences, and hemorrhoidal tumors of the uterus should be removed
by the knife. Aquapendente, who was much lauded, used for its accom-
plishment forceps with a scissors-shaped extremity, which saved him the
labor of first drawing out the polypus. Although here and there some
authors have called attention to this practice ; though Tulpius, Waters, and
Fronton quoted by Levret, each record an instance in its favor, it has not yet
triumphed over all the prejudice which theoretical speculation so long ago
created against it. M. Boyer, who reports that he has once successfully
tried it, and seems not far from giving it a preference, dares not however to
propose it formally for general adoption. It is condemned as being more likely
OPERATIVE SURGERY. 687
than any other to give rise to hemorrhage; to dangerous wounds of tlie rectum,
bladder, vagina, and even of the uterus, and also as being much less easy than
that by ligature. The wound which it must produce, has in its turn frightened
many surgeons, who have been afraid of inflammation in the gestative organ,
or of suppuration and an ulcer which it would be difficult to heal.
All the research, and all the dissection which I have made, along with those
recently performed by M. Hervez de Chegoin, have convinced me that all
polypi which are really fibrous bodies, may be excised from the uterus without
the slightest inconvenience. They never adhere to the organ by a peduncle of
any size, nor are supplied with any vessels. The layer of uterus which covers
them as a sort of hood is usually very thin, and constantly reduced to a mere
shell which has only to be incised to allow their enucleation, or turning out, to
be easily accomplished with the fingers or the handle of a scalpel, as if it were
a leipoma or a subcutaneous cyst. As to the homogeneous, hard, and greyish
bodies, like the preceding, which are continuous with the uterus, the section of
their pedicle can never bring about any alarming loss of blood, if I can judge
by those which I have seen in the dead, and removed from the living body.
Thirdly, I do not see either how the fibrous masses which originate in partial
hypertrophy of the uterus need justify the least fears on this subject. It is
rare for entire excision of the neck of the uterus to be attended with
abundant hemorrhage, and it is not easy to believe than removal with a cutting
instrument of the little, mucous, soft tumors described by M. Berard, or of any
other polypus production capable of being removed by ligature, should really
be rendered dangerous from such an occurrence. We have then, lastly, only
the reddish, bleeding fungi, sometimes painful and rarely pedunculated, of
which we before spoke, which can be unfit for the operation of excision : but to
them ligature offers no better a resource : for we are compelled to enrol them
in the list of those distressing affections which bafiie our art, and to which with
the greatest propriety the term " noli me tangere" may be applied. For
twenty years past M. Dupuytren has cut away every uterine polypus which
he has been called on to treat, and once only has the hemorrhage appeared to
him to demand any particular attention. Numerous facts equally conclusive
have been cited by M. Hervez de Chegoin. Operations, equally successful,
of this kind have been related by M. Villeneuve, M. Lejeune, and a host of
other surgeons. In Germany, MM. De Siebold and Mayor have published a
treatise to prove that excision, long practised by them in the Hospital at Vienna,
has been attended with remarkable success. May I be permitted to add, that
of eight operations for polypus with a cutting instrument, performed by myself,
not one has been followed by the least hemorrhage.
The Method of Operation. — The instruments, &:c., necessary for this ope-
ration, are the long forceps of Museux, a common bistoury or scalpel, some lint,
and some astringent preparation in case of need, and some linen, as for other
bloody operations. If the tumor be very large, a few more may however
become necessary ; such, for example, as forceps, sharp hooks, or what I have
sometimes used, long, strong double hooks slightly curved, to meet the shape
of the parts. In ordinary cases the right hand passes the forceps closed into
the vagina, and they are not opened except to seize hold of the tumor ; while
tlie left hand, while it protects the parts, directs the insertion of the hooks.
We are then to draw down the morbid mass, bv very moderate traction, by
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688 NEW ELEMENTS OF
degrees ; and if the mobility of the uterus permits us to get the pedicle to the
vulva, the labia are to be separated with great care by an assistant, and the
section is made with every facility by means of some cutting instrument or
other. When on the contrary the poljpus offers much resistance, we must
not permit it to reascend, but with the point of a straight bistoury, the blade of
which has been previously wound round with a strip of bandage, the surgeon
must proceed to divide it at its narrowest part, always following the knife with
the fingers of the left hand, which continue in the vagina. I had occasion to
remove from a young lady, living in the street of the "Petit Carreau," a polypus
as large as a turkey egg, which was inserted into the inner surface of the neck
of the uterus, and which after it was once engaged in the vulva, seemed not
willing to descend any lower. Whilst M. Cottereau, the physician to the
patient, retained it in the pelvic strait, I passed up my left index and
middle lingers towards the os tinc» ; then slipped a covered bistoury, with my
right hand between the polypus and my fingers, to the top of the vagina, with
which I easily detached the tumor. Not a drop of blood escaped, and the
the lady, after the third day, might have resumed her accustomed occupations.
An almost similar case has just occurred in my department at La Pitie.
If from the size of the polypus this cannot be done, we must use a bistoury
curved a little on its flat side, or else scissors of the same form. In those
cases where it would seem dangerous to make traction upon the uterus, we
should find an invaluable auxiliary in the species of forceps which is strongly
curved at one end, somewhat scolloped, and made to cut like the forceps of J.
Fabricius, of which we are told by M. Lauth, that M. Lobstein has often
made use. With the same view, M. Mayor contrived a long, and very strong
scissors, curved like the letter S, with which to detach the tumor whatever
might be its height. The same end may however be accomplished with the
equally long and strong scissors which are employed by MM. Boyer and Du-
puytren, and which have only a simple concavity on one of the faces of their
blade. They have besides an additional advantage, that of detaching gra-
dually the polypus from any adhesions which it may have contracted with tlie
sides of the vagina before it is drawn down, and its peduncle divMed, as hap-
pened in a case seen by M. Berard, in which the tumor adhered by one root
to the vagina and by the other to the uterus. If the tumor be separated from
the parietes of the organ from which it springs by a fissure of more or less
depth only, instead of having a foot stalk, and be also a fibrous body, we are
not to suppose it indispensable to carry the cutting instrument into the deepest
part of this fissure. If we can cut a little above the greatest diameter of the
polypus, and give the incision a certain length, so as to divide the whole layer
of tissue which surrounds the'morbid growth, we require nothing more than
the fingers, the handle of the instrument, or mere traction, to detach it, as a
nut is separated from the shell which surrounds it.
The membranous and irregular edge which result from the enucleation, either
retract and cicatrize or return on themselves, and are partially destroyed by
suppuration. Uterine polypi are sometimes so large as entirely to fill the
vagina, and even to rise up into the hypogastrium or fossa iliaca. Baudelocque
mentions having seen one of which the lower part was in the pelvis, and the
other projected above the superior strait. He succeeded in tying the lower
part, but when it had sloughed away, Louis objected to searching for the other
*^^ OPERATIVE SURGERY. 689
half with forceps. The woman died, and Baudeiocque asserts that it was
possible to have removed it as well as the other portion of the foreign body.
It is in cases like this that this author advises the use of those forceps which
Herbiniaux had used before him with complete success. All the advantages
promised by Baudeiocque has since been realized from their use by MM.
Deneux, Murat, and Hervez de Chegoin. Now that we have very clear ideas as
to the nature of these large polypi we shall attempt their removal with
more boldness, as we shall not feel compelled to resort any longer to the
ligature. After all, the forceps is not the only instrument, nor is it always
the best instrument indicated in these cases. In the month of September, 1830,
I was sent for to Bergues by Doctor Mazieres, to a lady who had been brought
almost to the grave by an enormous fibrous tumor of tiie womb, which rose
above the pubis, and entirely filled the vagina. Although firm and very elastic,
it could be so depressed as that the blade of the forceps continually slipped
backwards and forwards. 1 preferred seizing its summit with the very long
forceps of Museux, then to carry up above its thickest part two strong double
liooks, one on either side, and to fix them firmly into its substance. Thus
seized in four places at once, methodical traction at length brought it
into the inferior strait. The perineum, which I was obliged to cut backwards,
made long resistance; but at length my index finger giving me notice that the
pedicle of the polypus was strongly on the stretch, I slipped up on it a straight
bistoury properly protected, and an incision of a few lines allowed the elas-
ticity of the parts to finish the operation. It was a fibrous body, the size of
which was equal to that of a child's head. No bleeding followed, and not-
withstanding me emaciation and exhaustion to which the patient was reduced,
her health, as M.Demazieres wrote me a month afterwards, was perfectly re-
established. .
There are cases nevertheless in which such, is the situation of the tumor
that nothing seems capable of bringing it down. A woman, thirty-six years old,
was brought into my department of the Hospital St. Antoine, by M. Kapeler,
after a long residence in the medical side. In her the tumor filled nearly the
whole pelvis, and formed a considerable projection below tlie strait. It was
agreed between Kapeler and Marjolin and myself, that its extirpation should be
attempted by the natural passages. I seized it thrice with a common forceps,
and thrice I failed to effect its descent. I then, fearing I might unnecessarily
increase her sufferings, thought it best to leave her to the natural consequences
of her disease. In a few months she died. In the autopsy we found a fibrous
bpdy destitute of a pedicle, extensively putred, originating in the thickness of
the right wall of the cervix, from which it was otherwise easy to separate it
after cutting through the enveloping layer of natural tissue. Another tumor, as
large as the two fists only, in contact on one side with the former one, occupied
the right side of the uterus, and like it was covered by a thin reflexion of the
organ. These two masses, the base of which was as large almost as their greatest
diameter, and were larger above than below the strait, could not have
been seized firmly enough by forceps to have been drawn down and removed ;
but the dissection convinced us that their enucleation had certainly been
possible, notwithstanding the extent of the adhesions, if by any means we
could have brought then) to the inferior strait, or have carried the bistoury to
any point of their circumference. As this kind of polypus does not tear
87 ^^
690 , NEW ELEMENTS OF
very easily, it would not be iinadvantageous perhaps, when we have succeeded
in bringing them out at the vulva, to pass through them by means of a long
curved needle, having a handle and pierced near its point, a strong waxed
silk riband of which a loop might be made, and thus permit us to pull on them
without so much interfering with the other instruments.
If the tumor is of a doubtful nature ; if it be possible to draw it down by
seizing it with forceps so as to allow the finger to pass over the peduncle ;
if, as cases are quoted by Levret and Eschenbac, we feel arteries beating in
this peduncle ; and if, notwithstanding our dissertation on this subject fur-
ther back, we still dread the prospect of hemorrhage, there is nothing to
hinder the previous application of a ligature high up, as Mayor advises, before
we practise the excision.
In conclusion, let me observe, that neither ligature, tearing away, or exci-
sion is to be attempted where the tumor is still wholly enclosed within the
uterus, nor when we are satisfied that it is not the only one, and that others
exist in the thickness of the organ beyond the reach of surgical means. All
that the patient requires after the excision is injections, at first emollient,
then detergent, and finally astringent. If contrary to all expectation hemor-
rhage does ensue, I think that astringent injections, rolls of lint soaked in
oxycrate, eau de Rabel, solution of alum, or else besprinkled with colophany
or some styptic powder, would quickly put a stop to it. The tampon, if all
were vainly tried, should not as a last resource be omitted.
Art, 9. — Cancer of the Neck of the Uterus.
The amputation of the neck of the uterus, is a triumph of modern surgery.
Osiander was the first person who positively proposed it towards the end
of the last century, and who performed it in 1801. Tulpius, to whom it is
attributed by M. Tarral, seems to me undeserving of the honor. The sarco-
matous tumors of which he speaks were evidently polypi, which is moreover
proved by the figure of that which was removed from Ids patient Gertruda
Turrita. It is nowhere to be found, that he ever thought of exsection of the
fundus of the uterus. Lazzari, who claims it for Monteggia, and Baude-
locque, who assigns it to Lauvariol, have, I think, both fallen into an error;
and I cannot assure myself that it was performed by Andre de la Croix and
Lapeyronie, as is contended by M. Tarral. All that can be said is, that
Wrisberg recommended it in 1787, and that it was certainly done by many
persons through accident before it was ever designedly put into practice.
No sooner were the cases of Osiander known in France, than M. Dupuytren
hastened to put into practice the ideas of the Goettingen surgeon, and to test
them by many experiments. M. Recamier was not long in following in the
same path, so that in 1815 excision of the cervix of the uterus with us was
quite a common operation. It was reserved for M. Lisfranc yet further to
extend its usefulness, and to demonstrate to the most incredulous the very
little danger that attended it. It has now been done so often by so many
different people, that it is perfectly needless to enumerate the examples and
to reply to the objections made by MM. Wenzel and Zang, who have for-
mally denourxed it. The difficult point is to ascertain precisely when it is
indicated. The elongation from simple hypertrophia of the neck of the
OPERATIVE SURGERY. 691
uterus, does not require it ; for it is rather an infirmity than disease. It is
equally uncalled for by excoriations, ulcers, and syphilitic vegetations, which
are not incurable in their nature. The same thing may likewise be said with
respect to induration ; to those rugosities, unattended with pain, or with or
without chronic swelling, which are so often seen in women from thirty to
forty years of age. It is only in well characterized, real, cancerous degene-
ration, that we may be allowed to perform it. But here is precisely the
knotty point in the case; for so long as cancer is unulcerated, and presents
only a more or less tumid mass high up in the vagina, its diagnosis is
extremely difficult. In the first place it requires great familiarity with the
Iiardness and consistence natural to the neck, the variety of size, projection,
density, and of form which it presents, according to the age and different
conditions in which the patient may be seen, so as not to apprehend the pre-
sence sometimes of a disease of which no vestige really exists. How, indeed,
can we be sure that we mistake not as to the nature of an organic lesion, in a
part so deep, amid a texture so dense, and amid elements as variable? Nor
is this all ; were the existence of cancer to be incontestably established, it
still becomes necessary to affix limits to its spread. It is rare that all doubts
are entirely dissipated on the case until a very advanced period ; and then it
is almost impossible, to guarantee that the cervix uteri alone is effected, and
that the body of the organ is not more or less attacked. The surgeon is then
always in fear of, 1st, removing an organ which is not diseased, and of course
performing Unnecessarily a painful and dangerous operation, or else, 2dly, of
removing a portion of a disease only, the remainder of which will infallibly
result in the death of the patient. It is a natural consequence of these re-
marks, that the indication for the performance of amputation of the summit of
the uterus must be very rare ; and that one need not be astonished if very
well informed surgeons are yet in doubt as to its being ever a suitable one.
Since we could ask ourselves the question, what advantage arises from extir-
pation of this disease when it exists in the breast? it would be difficult to have
hindered its being asked when the affection was seated in the uterus. So
long as extirpation is admitted to be a remedy for external cancer, no one can
with reason deny its utility in cancerous diseases of the genital organs, when
done under certain conditions. It is even consoling to remark, that in the
latter parts, the disease remains longer a local one, and is in reality less
likely to reappear in other places, than when it exists in any other part.
I cannot myself, then, think this operation ought to be absolutely abolished
from practice. It is better to try it than to abandon the patient to certain
deatli, if the spread of it is such as to give any hopes of its total extirpation.
Two very different species of cancerous degenerations affect the cervix uteri.
Sometimes the disease progresses by ulceration either of the edges of the
neck, or of its cavity towards the thickness of its parietes; and the ulcers,
which are sometimes covered with fungous vegetations, not unfrequently
penetrate into the very interior of the uterus, almost as does the gnawing
cancer, the 710K me tangere of the face and mouth. Sometimes on the other
hand, a cerebriforme or scirrhous mass appears in the very thickness of the
organ, on or neir its free extremity, or at any other point of its extent.
Cauterizing. — Caustics can be applied only to the ulcerated form of cancer ;
for the tumors can be conquered only by extirpation, properly so called. I
692 NEW ELEMENTS OF
think, that as one is not sure, when the disease has not gone far nor deep,
whether it be of a cancerous rather than of any other character, we should first
make use of the argenti. nitras. In a more advanced stage of the affection,
and when its malignity can no longer be doubted, we may choose between the
muriate of antimony, caustic potassa, and nitrate of mercury; or even if we
are so disposed, try the effect of the actual cautery. But as our object is not
alone to destroy the tissues but to change the action on the morbid surface,
and the acid nitrate of mercury is of incontestible value in a host of other
affections of a like nature, I think that an advantage would ensue from its
general adoption.
The Operation. — After the woman is placed and supported on the edge of
a bed, and the parts diseased are brought into view by a speculum uteri, the
surgeon wipes and dries the ulcer by carrying up to it on a long pair of for-
ceps, small sponges or little rolls of lint. He then lays a little coarse lint
between the circumference of the cervix, and the inner face, of the speculunij
in order to prevent the caustic from spreading to the healthy parts, and passes
up the '* cautery stone" (composed of potassa, &c.), or else the nitrate of silver
in a conical shape, held in a very long porte-crayon, or one supported on an
another instrument to the bottom of the ulcerated excavation. If he prefers
the acid nitrate of mercury, he steeps in it a roll of lint or fine linen, and
carries it in like manner up to the parts. Before the speculum is withdrawn
repeated injections of warm water are to be thrown in, with a view to prevent
the action of the caustic from extending to other than the diseased spot. The
woman is then put into a bath, and afterwards subjected to the regimen
advised after the severer operations.
If the case were one of simple excoriation only, or of slight ulcerations, this
washing of the parts by injection would be almost unnecessary, and the other
precautionary measures scarcely needful. The operation is to be repeated
oftener or more seldom, according to the effects which result from it, o^wavy
four, six, or eight days; and it is only to be ultimately discontinued when the
granulated, scarlet appearance of the part seems to indicate the cicatrization
of the ulcers. When it has not been thought prudent to resort to caustics, or
when they have been tried with little or no benefit, and that otherwise we
are certain the whole of the disease can be removed, there can no longer be
any hesitation in deciding upon its exsection.
Anatomical Remarks. — In order fearlessly to amputate the cervix uteri,
certain anatomical details should be known. The vagina, which surrounds
this part, is thin ; in contact at one part with the bladder, at another with the
rectum, and continuous by its whole upper extremity with the proper tissues
of the uterus itself. In a natural state, this free and depending portion of
the organ of gestation is neither three, six, or eight lines in length, whatever
may be said about it; but sometimes one and sometimes another of these
dimensions, and that without being in any way diseased. The lips of the
OS tinc3e, which in women who have borne no children are closed, but in those
who have had families are naturally separated and frequently soft within,
knobbed, and as it were fungous even in some cases, and in others more or
less tumid, are moreover when in a state of perfect healthiness sometimes
greyish, sometimes purplish, sometimes more or less red in color. In mar-
ried NVwirien the anterior labium, which usualiv is more salient and thicker
OPERATIVE SURGERY. 693
than the posterior, is sometimes seen differently characterized. The vagina
may be detached from this anterior lip for more than half an inch without
risk of opening the peritoneal cul-de-sac which divides it from the bladder,
save that as the urinary bladder adheres to its anterior surface very closely,
there is a possibility that this part may be reached by the instrument. Pos-
teriorly, the peritoneum does not merely cover the corresponding surface of
the uterus. It passes down upon the vagina to form the recto-genital excava-
tion ; so that the bistoury on this side would have only to penetrate the thick-
ness of a few- lines to puncture it.
It was probably an oversight of M. Mury, who says in his thesis that there
is a distance of eight lines forward and ten backward between the summit of
labia of the cervix and the serous membrane of the abdomen. The two peri-
toneal reflexions which fasten the matrix in the pelvis contain only a few
vessels, twigs of nerves, and some cellular tissue. In a great many women,
being very lax, they permit us to make very strong traction on this organ
without any danger, and with scarcely any severe pain. Finally the structure
of the cervix uteri, being in a great measure destitute of venous or arterial
trunks, the bleeding which follows its exsection is very seldom alarming.
The imputation. — The method of performing excision of the uterus, did
not at once attain that degree of perfection which we see it has reached in
our day. Osiander began by passing two silk ribands, with the assistance of
a curved needle, through the diseased organ, which he drew and held firmly
down by the two loops, so as not to cut it until it came more or less near the
vulva. The introduction of two fingers into the rectum, permitted him to
cut it above when he could not bring it down ; but the invention of his hyste.ro-
/ame induced him to relinquish his riband tractors, which he had not used for
a long while before his death. M. Dupuytren, and most surgeons after
him, have used, instead of the ribands of the surgeon of Goettingen, a
Museux's forceps of great length, with hooks slightly curved, and which
easily embraces the diseased part. As this instrument easily tears through
the tissues it is sometimes advisable to insert two. M. Colombat has con-
structed one with four branches. Others contrived instruments which were
to be introduced through the os uteri into its cavity, and there opening
assume a hooked form, and drag it strongly downward. The most ingenious
one on this principle is that of M. Guillon. Another much more complicated
was proposed by M. Hatin, and M. Recamier has since invented ' others.
Osiander neglected the use of a speculum. Witli us, on the contrary, it is
almost constantly put in requisition ; and many persons have been concerned
ill bringing it to perfection. That first proposed by M. Recamier was a
simple tin cone. To it M. Dupuytren added a handle, which rendered it
much more convenient in its application. The ancients possessed one, which
is engraved in the works of Pare, Joubert, Manget, and Scultetus, composed
of two valves, susceptible of being approximated or parted at pleasure.
Following this principle, that of Mdme Boivin is made in tv/o half cylinders,
and has at its large end a handle ending in two rings or circles like a pair of
forceps. This is introduced closed into the vagina, and by pulling in different
directions the two halves of the handle it is made to open a pair of scissors,
and to enlarge the canal to be explored as much as is requisite. M. Lisfranc
has constructed one different from this^ only in having: its summit a little fiat-
k
694 N£W ELEMENTS Ot
tened, elongated, of greater thickness, and the handle destitute of rings.
For the purpose of keeping it open at the suitable width, M. Guillon has
added to it a stem, a kind of slide, which detached by the finger allows it to
close instantly. The same practitioner, to avoid pinching the tissues, which
they are very liable to when the ordinary speculum is used, adds to his, when
introduced, a third piece. This plate is made to slide from the base to the
point of the two principal halves of the instrument, along a groove which there
is on the inner surface of the free edge of each.
Not satisfied with a double branch speculum, the triple speculum, of which
drawings also exist in the ancient works of which I have spoken, has been
revived. But as it is especially necessary to dilate the upper part of the
vagina, MM. Bertze and Colombat have endeavored to produce a specu-
lum, of which the base, when the instrument was closed, was to be at the
handle, but at the opposite extremity when open. That of Bertze is com-
posed of two tubes, enclosed one within the other. The inner tube which is
divided at its upper part into several elastic branches, is so disposed that
these branches separate by their own resiliency when they are set loose, by
drawing towards you the tube which serves as their sheath. Eight pieces
constitute that of M. Colombat, which together form a hollow cone whose
point may be narrowed or opened at pleasure when introduced by means of
return screws placed at the two extremities of one of the great diameters of the
base. The instrument when open represents a sort of grating, which easily al-
lows of our seeino; the neck of the uterus and interior of thevao;ina at the same
time. Of all these varieties of the speculum, the perfected one of Mdme. Boivin
appears to me the best. The only reproach which I can make it, is the in-
convenience of admitting the entrance of the mucous membrane between the
edges, and allowing it to be pinched by them when the instrument is closed.
But this objection, which the proposed modifications have as yet very imper-
fectly remedied, applies with much greater force to the three branch speculum
of M.Hatin, to that of M. Colombat, and even that of M. Bertze, which may
moreover injure the organs with their points, and do not reflect the light with
equal distinctness. With regard to this latter consideration, the primitive, or
cylindrical speculum, is still the best, not excepting even the cribriform, or
perforated speculum of M. Ricque.
Many kinds of cutting instruments have also been tried. M. Dupuytren
has often used with advantage a sort of curette or trowel, slightly concave ;
which cuts only at its upper extremity, which is convex, and of a semilunar
shape. By a circular motion this instrument cuts the cervix uteri at the bottom
of the speculum very well, and might in fact penetrate within the Uterus, as
if to hollow out the organ conically, and remove all the morbid tissues.
M. Hatin employs a forceps terminating in two cutting extremities, like the
spoon-shaped instrument of Fabricius ab Aquapendente, or the forceps of M.
Lobstein, to the stem of his principal instrument.
Again ; the apparatus of Colombat is so constructed that his crotched
forceps carries with it a stem; at the end of which is a little blade placed
crosswise, which by a particular contrivance may be depressed or raised, and
which cuts very neatly when made to turn upon its stem all around the cervix
above the hooks.
Nothin?- has been invented, even to the ligature recommended by M.
OPERATIVE SURGERY. 695
Lazzari, which has not had its partizans, and which may not, in fact be put
in practice. M. Mayor thinks, and not without a show of reason, that by
carrying a silk riband up above the disease, by means of the instruments he
has for conductors, it would be very easy afterwards to strangulate it with
his fillet for effecting constriction.
The truth is that these shades of difference reduce themselves to two
methods ; one, that which attempts the descent of the neck as much as possible
before it is cut; and the other, that which prefers cutting in its natural
situation. The latter, at first sight, would seem the preferable one, insomuch
as it precludes all kind of pulling and laceration. But it is nevertheless,
much the least advisable of the two first, because it does not admit of an
equally exact appreciation of the state of parts, and of getting equally near
to the uterus itself; and then, because it is in fact, much less easy of execu-
tion. It deserves a preference, only in those cases in which the uterus is so
firmly immovable, as that the ablest combination of tractive efforts cannot
bring it into the inferior strait, which must be a very rare event, for to cut off
the OS tincai with any chance of success, the disease must be complicated with
no other affection and with no alteration in the uterus or its appendages. The
fillets of Osiander since the improvements made in the crotchet forceps can no
longer be retained in use in the first method. To me the speculum, which-
ever it may be, seems much more embarrassing than useful. Directing their
introduction with the fingers of the left hand, it can never be very difficult
to place the forceps around the neck, and no one can doubt the greater facility
of manipulation in a free vagina. If it becomes necessary to multiply them
to prevent any tearing whatever of the parts, it is certainly better to imitate
MM. Dupuytren and Lisfranc, and place a second pair of forceps above, or
in an opposite direction to the former. I have always found the straight
bistoury, wrapped round with its little bandage to a short distance from its
point, more convenient than any other, as it may be carried so far up into the
vagina. I have only to add that instruments of traction which unfold in the
Interior of the organs, are dangerous for the most part, and should be formally
proscribed. It is difficult to do without a speculum, when the cervix has to
be excised in its natural situation ; and the " speculum brise," owing to the
want of space and freedom of motion, is in this case the only one which can
answer tlie expectation of the surgeon. Then also the scissors slightly curved,
the cutting ring, the curette of M. Dupuytren, or the bistoury concave on its
flat side near the point, would come into use.
The Method of Operating. — The speculum being selected, one or more for-
ceps of Museux, the bistoury which one prefers, the scissors or curette, some
lint, compresses, and a T bandage are all the things that are wanted. The
position of the patient is the same as in applying the caustic. One assistant
holds her head and arms, two others take charge of the lower limbs, a fourth
hands the instruments as they are successively needed. The surgeon seated
in front of the vulva, begins, if he has resolved upon using it, by introducing
the speculum ; after he has besmeared it with cerate he slides it gently in the
axis of the pelvis, pressing principally on the posterior commissure of the pu-
dendum, and so passes it up to the seat of disease ; then as the cervix presents
more or less perfectly at its extremity it is to be turned forwards, back-
wards, or sideways ; whereas, if it be the speculum '' brise" it is to be
696 NEW ELEMENTS OF
opened so as to spread asunder the wliole vagina, and expose the whole extent
of. disease. If we suppose that he wishes to leave it in that particular situation
to apply his forceps, he gives it in charge to an assistant, until he has properly
disposed of them. He then withdraws it, and the speculun *'brise/' here offers
a very great advantage in allowing of the easy disengagement of the forceps
above. If he neglects to employ a speculum, two fingers of the left hand are first
to be carried up into the vagina; whereafter having examined the form and
extent of the disease, they are to remain. The closed forceps is then passed
up on their palmar surface, which is opened when it reaches the cervix, and
applied as high up as possible, so high at least as that the hooks may be fas-
tened into a healthy part of the uterus. With this forceps, which is to be im-
planted rather by pushing than pulling, he makes gentle traction, and endeavors
to bring the part down into the vulva. It is better in making these tractive
efforts, to employ only the right hand rather than both, acting always in the
direction of the pelvis, and to use the fingers of the left hand to protect the
hooks of the instrument, which should never be abandoned. If he perceives
the forceps to slacken their hold, or that the points are about to tear what
they embraced, he immediately gives the first pair to an assistant to hold,
and inserts a second into the opposite diameter of the cervix.
When the parts appear outwardly, he has the two sides of the vulva parted
carefully, gives the instrument or instruments of traction to some one, calls
for his bistoury, carries it in the first place to the right side, and always above
the disease, brings it forward ; then over to the left side : or he might perform
the section of parts from behind forward, and from left to right. If the
affection seems not entirely circumscribed he should proceed to detach the
adhesions of the vagina one by one, so as to remove not only the os tineas, the
upper part of the neck, but also to hollow out conically the inferior part of the
uterus itself if it appears to him to be necessary. As soon as the section is
finished the fundus uteri rises and resumes its natural situation. If some
portions of diseased tissue or cancerous tubercles have escaped the knife, we
must reintroduce the speculum, seize them with forceps, and without hesita-
tion cut them away or destroy them by caustic. When, as happens in an
immense majority of cases, there follows no bleeding, no dressings are required.
Injections of tepid water, or of cold water as is advised by some, for a few
days is all that is done. I can see however no objection to slipping up to the
bleeding surface a shift-shaped piece of fine linen, to be softly stuffed with
balls of lint, if blood should flow too abundantly, and the state of the patient
such as to make us lose nothing. This shift would render plugging very easy,
and would expose to no danger which was not easily remediable at the
moment.
Thus far I have performed twice only excision of the cervix uteri; in
neither case did I require any thing besides Museux's forceps and a straight
bistoury. In the first female I removed the whole neck. The operation was
quickly over, easy, and gave but little pain. Some blood flowed, which simple
means soon arrested ; yet she died nevertheless on the third day afterwards.
On opening the body, neither peritonitis nor any other appreciable lesion was
discernible. The remainder of the uterus was healthy, iDut a small cerebri-
form mass existed on the right side behind the vagina. An aperture of two
OPERATIVE SURGERY. 697
lines in width occupied this side of the vulvo-uterine canal, and communi-
cated with tlie genito-rectal excavation. We could not determine whedier it
was effected during the operation, or in the autopsic dissection. It was quite
certain, however, that no fluid had been effused from it.
In mj second case, having experienced some difficulty in bringing down
the cancer to the orifice below, I carried up the straight covered bistoury
without any great trouble, to a depth of two inches into the vagina and above
the limits of the disease, and directing its progress on the palmar surface of
tlie fingers of my left hand, thus completed the operation. This patient who
at first appeared to be doing well, died at the end of six weeks. She had
several cerebriform tumors existing on the right lumbar region and deep in the
right broad ligament of the uterus. A patient on whom M. Blandin operated
died of uterine phlebitis. One of those whom M. Lisfranc lost, perished
from peritonitis ; others are carried off by a state of nervous depression, of the
severity of which it is impossible to assign any explanation. Thus far, no one
has fallen a victim solely to the loss of blood. MM. Rust and Grsefe of Ber-
lin, MM. Roux and Dupuytren, who have seen several die owing to the imme-
diate sequelae of this operation, have never attributed the fatal issue to this
occurrence. Exsection of the cervix of the uterus, then, though easy and
often unimportant, is nevertheless sometimes extremely dangerous and
speedily fatal. Nay, from the view taken of it in the beginning of this
article, it should seem that success could follow it but seldom. ButOsiander
for all this perforiped it eight and twenty times ; M. Dupuytren fifteen or
twenty times ; and Lisfranc forty or fifty times, with not more than one case
fatal in six or seven. Women on whom it had been performed have
repeatedly become pregnant, and have been delivered without accident. M,
Dupuytren even relates a case in which he repeated the operation for a return,
of the disease, which recovered also the second time. Lastly^ it is said, that
cures thus effected are in most cases radical ones.
I shall not enter on a consideration of the question, whether since it has
been practised, excision of the cervix uteri has not been performed very often
when no cancer existed in it, as some persons have asserted ; but shall con-
fine my remarks to stating that M. Dupuytren, who, as it were naturalized
the operation in France, now seldom resorts to it; that M. Lisfranc, in
whose hands it has been so successful, does it much more seldom than for-
merly ; and that, according to M. Heisse, Osiander himself had ceased to
perform it at all for sometime before his death.
The two instances recorded by M. Stoltz of Strasbourg are certainly not
more calculated to exalt our idea of its utility.
Art, 10. — Extirpation of the Uterus,
Historical. — Removal of the uterus has so long been looked upon as an im-
possibility, that it has been doubted, even in our times, whether it had ever
really been done. A difierent opinion has prevailed among some authors,
however, in almost every age. Soranus, to prove the unimportance of this
organ to the woman, states that it may be removed without fatal conse-
quences ; '* as," he adds, '^ is testified to in the works of Themison ;" and he
even goes so far as to enforce the operation as a precept ; for he advises that
88
698 NEW ELEMENTS OF
when it putrijies it is immediately to be extiq)ated, without any reserve, and
positively asserted that its entire removal has sometimes been done with suc-
cess. In Bauhin's additions to the work of Rous?et may be found nineteen
cases which evince the boldness of the physician of Ephesus ; while Schenck
of GrafFemberg relates a still greater number."
All these accounts, however, as there are amongst them so many which are
wanting in authentic proof or sufficiency of detail, have been rejected as in-
conclusive ; and with greater propriety as many were performed by midwives,
many by quacks, and again many by very ignorant surgeons; and that
besides, it is so easy to be deceived by inversions of the vagina, polypous or
sarcomatous tumors, that unless the facts had been established by autopsic
examination, the mind must continue to entertain doubts as to their truth.
Rousset in his book gives moreover so many evidences of a want of fidelity,
and Bauhin and Schenck seem to have been so credulous, that one is naturally
led to doubt their testimony. Who can believe that extirpation of the uterus
was performed on the woman spoken of by Plempius, who notwithstanding
afterwards became pregnant ? In the other, who according to Plater retained
her sense of venereal enjoyment, and continued to menstruate ? In the third
quoted by Schenck, from Carpus, in that mentioned by Morgagni, from Wei-
deman, all of whom presented the same phenomena ? Is the testimony of
Vieussens a much more credible authority, at all events more conclusive, who in
giving an account of an examination of a female in whom the matrix had been
removed fifteen years before, admits that a portion of the organ was left at
the fundus of the pelvis.'^ And the case of Pierrette Boucher, who had been
operated on three years previous, and whom Rousset caused to be disenterred
three days after her death, and opened before a physician and' a midwife not
named, may not this be an account of pure invention got up for the occasion r
Yet it cannot be disputed now-a-days, that removal of the uterus has
several times been performed, and that in some cases the patients have sur-
vived it.
Not to speak of those cases cited by Moschion, Avensoar, Rhazes, Mercu-
rialis, Woega, Fernel, and others, we meet with one in the works of Pare
which cannot be considered as doubtful. The operation took place on the
King's day, 1575, and the patient lived three months afterwards, and died of
some other affection. On the examination of the body, Pare demonstrated the
absence of uterus, and he remarks as a circumstance deserving of notice, that
nature had confined herself to building (batir) a mere hardness at the fundus
of the pelvis, in room of the extirpated organ. Under this view of the sub-
ject, the principal facts known as to the early history of this proceeding,
may be arranged under two principal categories. In the first, prolapsus of
greater or less standing of the organ existed ; the second relates to it in a state
of inversion. Among the former, we place the account given by H. Saxonia,
of a Venitian servant woman, who tore away the prolapsed utems with her
own hands ; the cases by Paul of Leipzig ; by Cohausen, Tencel, Goulard,
and also tliose which have since been made known by Laumonier, in 1784,
Clark, Vanheer, A Hunter, in 1797; by M. A. Petit, Hosack, Galot de Proj
vius, in 1809.
Should all these relations not be adopted as facts, and it appears evidei
that Liaumonier, and Bardol amongst others, removed merely a polypus, and n<
OPERATIVE SURGERY. 699
the entire uterus, the same thing cannot possibly be said, as to M. Galot, who
conveyed the specimen to the Society of the Faculty of Medicine at Paris ;
nor as to M. Marschall of Strasbourg, to whom an opportunity was afforded
ten years afterwards, on the death of the woman, to prove by the dead body
the removal of the gestative organ.
In 18£2 this operation was successfully performed by M. Langenbeck.
The cases published by M. Fodere in 1825; those of MM. Recamier and
Marjolin, contained in the Revue Medicale of 1826, as well as that just an-
nounced by M. Delpech, admit no longer of any hesitation on the subject;
and it is clearly proved that the prolapsed uterus has frequently been re-
moved from the living subject unattended by a fatal issue.
Under the second series of the categories, which like the first contains its
doubtful facts, and others more or less certainly true, may be included the
case related by Ulm, who states that a midwife in pulling at the cord,
having inverted the uterus excised it at one stroke of a razor; the other by
Bernard, nearly alike, except that the woman recovered ; a third of the sam.e
kind related by Wrisberg; that by Viardel ; a fifth which occurred in Lower
Poiton and published by Caille ; that recorded by Anselin, of Amicus, ia
which he himself removed the inverted organ. To it likewise belong the
cases of R. Baxter, Mullaer, Jean Muller, and of Sorbait; those related by
Figuet of Lyons, by Faivre of Vesoul ; as well as that in which it is said
that Desault excised a portion of an inverted uterus in the removal of a
polypus. Without including in the account the cases of Gattinaria, of
Berenger de Carpi, and Fonteyn, mentioned by M. Dezeimeris, there must
still be added to this list those by Messrs. Charles Johnson, in 1822, Newn-
ham and Windsor, (1809,) Rheineck, Davis, Chevalier, Weber, Dj-. Gooch,
Cordeiro, &c. It is owing to the distinction not having always been made
between removal of a uterus previously prolapsed out of the pelvis and that
of one in which no displacement from its natural seat had occurred, that all
the doubts and vagueness about this latter operation have existed, even to the
period in which we live. Without such a distinction, it is in fact impossible
to understand the subject; for the two circumstances are far from identical.
1st, Of the Displaced Uferus.'—When every attempt at reduction has been
made in vain, and the disease threatens to destroy life, the operation before
us becomes indicated; but it is at the same time to be remembered that pro-
lapse merely of the uterus is rarely fatal; that it may be a mere infirmity;
that it often allows of pregnancy within it, as is proved by the case reported
by Marigues of Versailles, and that of M. Chevruel; that usually the general
health is but little impaired ; and that in order for a surgeon to decide on this
step, some degeneration or morbid condition in itself dangerous must be
superadded to the descent of the organ. It is usually so easy to reduce
its inversion after delivery of the foetus, that it is only an exception to the
rule that it can require the performance of so dangerous an operation.
If however the woman should have been ill treated ; if brutal and ignorant
manipulation have induced gangrene, or disorganization of the uterus, to a
degree which precludes all hope of its reduction or preservation, exsection
presents a resource of which we should do wrong not to avail ourselves. It
ought to be a rule never to separate from the body a uterus which has
descended out of the pelvis, without some very clear and urgent necessity.
700 NEW ELEMENTS OF
Admitting, as proved, the occasional successful result of its removal, it is but
just to confess the dangers which attend it; and not to forget that the woman
spoken of by Blasius, Farbricius, Hildanus, and Ulmus, operated by their
midwives, all died; that the patient of MM. Recamier and Marjolin
survived only two months ; that an unhappy woman received at La Charite,
in July 1824, whose uterus had been tied eight days before by mistake, died
also in a few weeks after; and lastly, that if the facts related by MM. De
la Barre and Baudelocque, in which a spontaneous disappearance of an
inversio uteri occurred at the end of several weeks in one woman, and after
lasting seven years in the other person, be correct, amputation of it in such
cases can be seldom indispensable.
Method of Operation. — Those who have performed this operation of abla-
tion of the uterus through ignorance or rashness, have done it in a manner
that deserves no discussion. No one now would think of tearing \i away,
or excising it with a razor or kitchen knife, without any previous precaution ;
or of hot coals or other caustics which have been employed by some women
on themselves, by quacks, matrons, and the older authors. The rational
methods, from which we may be permitted to select, are strangulation, with
or without immediate amputation; pure or simple excision ; and extirpation,
with a dissection of the peritoneum.
Ligature is extremely easy, for beneath our eyes we have the pedicle
around which it is to be placed. But then the pedicle is rather large, and the
pain caused by its constriction has at times been so excessive as to threaten
the life of the patient ; so much so, that in M. Marschall's case, among others,
it was necessary to cut the thread very soon; and resolve upon excision at
once, which was entirely successful.
By using a ligature, moreover, we run the risk of including the urethra, as
was seen by Ruysch, or a kunckle of intestine, as did a quack mentioned by
Klein, or the bladder, &c. Mr. Windsor, with a view of performing a more
speedy section and of giving less acute pain, pierced the root of the tumor, as
Faivre had done before him, with a double riband, so as separately to encircle
both halves. The observation of Clark, Neunham, and Recamier, proves that
an ordinary ligature is not always dangerous.
By excision the patient is more quickly relieved. As the ligature can be
of no use but to prevent hemorrhage, one does not see the advantage there
would be in trusting to it alone the destruction of the uterus. If strangulation
then be adopted, either simple or by dividing the root of the body to be cut
away into several portions, to me it seems advisable to cut away immedi-
ately afterwards the parts which are beneath it. This was done by Baxter,
Bernard, and a host of others. To avoid wounding an intestine, or the
apparatus for the excretion of urine, it is sufficient to impress a few gentle ^
shakes on the pelvis, by having it raised on the bed above the other parts of S
the body. Besides this, the pain which ensues from pinching an intestine,^'
the only accident which can happen of this kind, and which cannot be always
avoided, will quickly indicate its occurrence, and can be easily remedied
without delay; while the bladder and urethra would always be out of the way,
of danger, unless the riband were carried very high up indeed, which wasj
done by a quack whom Ruysch mentions. The multiple ligature, which has
undoubtedly the same advantage here as in epiploic hernia, gives less pain,
OPERATIVE SURGERY. 701
because it causes less traction and folding in on the root of the organ, cuts
the parts more quickly, and is less disposed to slip or slacken, when excision
is conjoined to its application, than a common ligature is.
It appears to me that excision of a prolapsed uterus of long standing ought
not less generally to be preferred to ligature. The only risk attending it is
of hemorrhage. Now the vessels which the peduncle of the tumor contains
are not large enough to make this dread a very serious one. Moreover
what is to prevent us from using the ligature to it, if it should appear ne-
cessary, or else employ topical astringents, tampons, or the potential cautery.
Excision, as it is more prompt and less painful, offers a great advantage over
strangulation, and ought to ensure a greater ratio of successful results. It
was that which was practised on the patients of whom Pare, Bernhard, &c.,
relate the cases. I do not see the benefit of imitating M. Langenbeck's
proceeding. The female on whom he operated, had an incomplete prolapsus
with scirrhous degeneration, like those of MM. Ruysch, Hosack, Wolf,
Fodere, and Recamier. This surgeon thought it necessary to dissect oft'
cautiously from the exterior to the interior the whole of the uterine reflexion
of the peritoneum, so that after removal of the organ this membrane was
found to be uninjured. It is true that his patient got perfectly well, and is
living to this day. The passage of air into the abdomen through the vagina*
which is thought possible even after recovery by Rousset, who has cited a
case, and by Siebold, who attributes to it the death of one of his patients, is
thus surely prevented. Let it be observed, that all this latter apprehension
is mere assertion, easy to refute : and that if M. Langenbeck's plan is to be
followed it will become one of the longest and most difficult operations in
surgery.
Qd. The Uterus not Displaced. — A question which naturally follows the
preceding observMlons, is that which relates to removal of the entire uterus
from its natural situation. If Lazzari is to be credited, this operation has
been thrice performed near the beginning of this century by Monteggia.
Siebold asserts that it was once done by the elder Osiander, and with success.
It is at least certain, apparently, that it was really practised, April ISth,
1812, by M. Paletta — but on his part undesignedly. He meant to remove
nothing but the cervix which had become cancerous, and only discovered
that the entire uterus had been exsected, upon examining it after the opera-
tion. To Doctor Sauter, of Constance, then the merit is due of having first
conceived "the project of this operation; and of having executed it after a
rational method and upon fixed principles. It may now be asked, whether if
exsection of the uterus be really practicable, it is useful; and in what
manner it may become dangerous. A few words on each of the cases we are
acquainted with will enable the reader to decide these points for himself.
M. Sauter's patient died four months after the operation, which was on the
22d January, 1822; and, says the author, of a paralysis of the lung; the
bladder had been injured. On the 5th of February, 1824, M. Hoelscher
followed the surgeon at Constance. In twenty-four hours the patient died ;
and the body showed symptoms of peritonitis. The woman on whom Siebold
operated, April 19th, 1824, lived sixty-five hours only, and she died of peri-
tonitis. In the patient on whom M. Langenbeck operated January 1 1 th, 1825,
and who died in thirty-six hours, traces of peritonitis were also visible. Sie-
702 NEW ELEMENTS OF
bold performed the same operation on a second woman, on the 25th July,
1825. She was dead on the following day, and with the same phlogosis as the
others, besides evincing, when opened, many organic lesions which ought to
have been known beforehand. On the 5th August of the same year, M.
Langenbeck had recourse for the second time to extirpation of the matrix,
and the woman who died in fifty hours after, offered, as did the others,
incQntestible evidence of peritoneal inflammation. Of four patients on whom
Br. Blundell operated, three died — one after thirty-nine hours, another in
nine hours, and the third very quickly ; but the precise lesions which were found
on examination of the bodies are not known. The first of the four who had
been supposed cured, died, at Guy's Hospital a year afterwards of a return of
the cancer, Mr. Banner's patient, on whom he operated on the 2d Septem-
ber, 1828, died on the fourth day of peritonitis. Mr. Lizars of Edinburgh,
wishing to follow in the steps of his two fellow-countrymen, performed the
same operation on the 2d of October, and the patient died within the twenty-
fi)ur hours. M. Langenbeck, a third time repeated it in 1829; the patient
survived only a fortnight. On the 26th July, 1829, M. Recamier, first per-
formed it in France. He appeared to have better success than any preceding
surgeon, yet like Dr. Blundell he had the misfortune to lose his patient at
the end of a year's time ; unfortunately no autopsia could be made. I have
only learned that she sunk under chronic diarrhoea and a long continuance of
febrile irritation.
In September, 1829, M. Roux performed the operation in his presence ;
the patient in his case dying on the evening of the next day. The professor
a few days afterwards again practised excision of the uterus, but under very
unfavorable circumstances. The operation was long and painful ; abundant
hemorrhage ensued, and death resulted at the expiration of twenty-five hours.
M. Recamier did it again on the ISth January, 1830. Here also consid-
erable bleeding occurred, and the woman lived only thirty- three hours. M.
Dubled, operated on a case on the 20th June, 1830, which survived only twenty-
two hours, and died of symptoms of debility, of which the examination of
the corpse furnished no explanation. M. Delpech, who in his turn thought
fit to attempt its performance, was not more successful than others; his
patient died on the 3d day, but not he assures us of peritonitis. The En-
glish Journals, give a last case, that of Mr. Evans, and which seems to have
been successful ; but I have not accurate details enough about it to speak of
it more fully.
We see by this enumeration, rejecting the doubtful cases of Monteggia
and Osiander, and including that of M. Paletta, whose patient perished on
the 3d day of highly acute peritonitis, twenty-one performances of the abla-
tion of the uterus, perfectly authentic and incontestible, all done within
twenty years, and not one permanent cure eft'ected out of the whole number !
Is there a more appalling statement to be met with in the records of surgery ?
And is not this melancholy result sufficient to banish this operation from
practice for ever ?
For all this, the disease which it is performed to remove is so common, so
invariably fatal, and leads to the grave through so much pain and anguish,
that this last hope will not be abandoned without regret which seems occa-
fiionaUy to have been opposed to it with some success; some persons will
OPERATIVE SURGERY, 703
again probably venture upon its repetition, and the preceding facts will not
appear to all such as to warrant its final and complete proscription. Amid
the dangei-s to which it exposes the patient, that of peritoneal inflammation is
of chief importance. But yet in every case this result has not followed.
The patients of MM. Sauter and Recamier and of Dr. Blundell, who
survived its performance, were not affected by it, nor did the bodies of all
who died evince its uniform presence. To this it can be replied, that with
regard to those who died the most speedily, say in less than twenty-four hours,
peritonitis could not have yet developed itself, although even it were a neces-
sary consequence of the operation. On the other hand, if it be considered,
that traumatic peritonitis may often be averted, and that medical art is not
without the means of subduing it when it is developed, it does not follow that
on this account ablation of the uterus must be driven from practice.
Hemorrhage is another occurrence of great moment, and often serious ;
many have been attacked with it, as may be seen in the cases operated on by
M. Roux and Recamier, and as has happened also in Germany and in Eng-
land. Still in the majority it did not occur, and we may be permitted to
express the hope that the perfection which operative medicine is attaining
will some day or other enable us to avoid it with consideiable certainty.
Some it is said have sunk beneath the exhaustion of suffering and distress.
Be it so ; to this at least, in part, a remedy will, we may hope, hereafter be
provided from the nature and position of parts to be removed. It is yet a
question to be solved, why women who have survived the first and violent
tempest and the immediate consequences of the operation, have continued to
languish, and have died at last ? For this event, neither peritonitis, hemor-
rhage, nor suffering can be held responsible. To those who think that the death
of these females was owing to the privation of uterus simply, the case men-
tioned by Vieussens, which survived fifteen years, that of M. Marschall,
whose patient died at the expiration of ten years, and that of M. Langenbeck
who is yet living, from all of whom the prolapsed uterus had been removed,
will be a sufficient answer
Whatever it may be, we see what chance is offered of recovery from extir-
pating a cancerous uterus when performed under those circumstances in
which only it is admissible to attempt it. If we seek to reduce these con-
ditions to great preciseness we shall find it no easy matter, and shall discover
how very rare their combination in one person must be. So long as cancer
has not attacked the whole organ, pure and simple excision, which admits of
our ascending very high up, ought to suffice, and should alone be essayed. It
was by means of excision, that Bellini extirpated the lower half of the uterus,
in 1828, with complete success. It was excision also which M. Dubled pro-
posed as a substitute for ablation or extirpation in his work which was pre-
sented to the Academy. But when, on the contrary, the disease possesses the
whole uterus, how can we be certain that it has attacked no other organ also.
It is very true that by introducing the finger alternately into the vagina and into
the rectum, whilst the other hand is applied to the hypogastric region, we may
often acquire motives for suspecting the existence, or of believing on the non-ex-
istence of material alteration in the pelvis, in the region of the ovaries and their
tubes ; in a word, of the uterus and its appendages ; but the most experienced
pracl^tioner even then can learn but greater or less probabilities, and never
r04 NEW ELEMENTS OF
attain to any 'certainty of opinion. Shall we then with all this uncertainty de-r
cid^ upon the performance of this fearful operation ? To render those proceed-
ings with which we are acquainted proposable, even when the uterus alone is
supposed to be affected, the organ must at least preserve its natural mobility,
and be free from unnatural adhesions. Now whilst it is found under these cir-
cumstances, it is not in all probability throughout diseased ; and if so theadea
of its excision ought to present itself to the mind. How, lastly, are we to
decide in an early stage of disorganization, by merely feeling with our fin-
gers through the parietes of the abdomen, rectum, and vagina, that the body
of the uterus is really cancerous, or that it is a little smaller, or a little larger
than usual in a normal state ? Two principal methods, the one called hypo-
gastric, the other sub-pubic, have been projected for extirpating the uterus.
If Musitanus is to be credited, extirpation of the matrix through the hypogas-
trium is far from being as novel as is generally believed. In fact, this author
says, according to Wier, that a girl of exceedingly salacious disposition was thus
n-jperated on by her father, who made an incision into the lower part of the
abdomen, and through this sought for the uterus and removed it on the spot.
It is however probable, that the peasant of whom Musitanus speaks did no
more than remove the ovaria, which is done to the females of domestic
animals, but without touching the womb itself. The same remark applies to
passages in J^^tius, Schurigius, add others ; wherein it is stated that surgeons
liave ventured to open the abdomen of certain women and to take out the
gestative organ. Be this as it may, the hypogastric method was described and
proposed, in 1814, by M. Gutberlat, who upon the subject enters into the most
circumstantial details. He makes use of a sort of ring fixed upon a long
hanflle, which is carried into the vagina, and by embracing the os tincae, serves
U) fix tlie organ in the abdomen. He then makes an incision of sufficient
length, in the extent of the linea alba, above the bladder, which allows of the
introduction of his left hand into the abdomen, and then with scissors carried
in by the right hand he is enabled to detach the broad ligaments and upper
extremity of the vagina, and extract the uterus entire. It does not appear
that the author ever practised his method upon the living subject. Judging
from what occurs in the dead body, the ring, &c. of which he speaks can
answer only when there is no enlargement of the neck ; and it would be
moreover a very hazardous means of protection to the bladder, and not to be
relied on. The separation of the uterus is really very easy in this way. I
aelieve that M. Langenbeck was the first person who ventured to perform it
during life. But with as light variation from Dr. Gutberlat'S method, he
advises, that before meddling with the uterus we assure ourselves by the
finger and eye of the condition of the tubes and ovaries, that they may equally
be removed if they participate in the disease. And he likewise thought it
better to open the peritoneum from the vagina, as a greater security against
Injuring the bladder. Many of the modifications of this able surgeon, are
however unfortunately more apt to complicate than perfect the hypogastric
method as recommended by Gutberlat. This method has also been put to
the test of experiment in France by M. Delpech, who prefers previously to
detach the uterus forwards by the vagina, and that to get at it across the
hypogastrium a semilunar incision be made in the side of the median line,
;he convexity of which is to look outwards, so as to have a large flap, which
OPERATIVE SURGERY. 70$
being turned back on its right edge, gives room to the surgeon to manipulate
freely at the fundus of the pelvis. If it should be ever proved, that large open-
ings may be made into the parietes of the abdomen without danger, the hypo-
gastric method, more or less perfected, would ultimately make extirpation of
the matrix easy enough to do. But it is not the way to make it of general preva-
lence to combiHe the sub-pubic operation with it, any more than the incision
into the perineum, as proposed by Frere Come, to bring about the adoption of
the sub-pubic operation for stone. One operation is quite sufficient without
combining the two. Of the twenty-one cases known in which removal of the
uterus was practised, nineteen were performed by penetrating from below up-
wards. M. Sauter, who could not bring down the organ as was done by Osian-
der, divided the vagina ascendingly by small incisions on the anterior surface
of the cervix uteri, succeeded in anteverting the organ, separated the broad
ligaments successively, and finished by gradually isolating it from the rectum,
Hoelscher and Siebold operated in almost the same manner. Once however the
latter was obliged to cut the vagina laterally, to facilitate the introductions and
motions of his fingers within. He also thought it advisable to take the precau-
tion of introducing a catheter into the bladder, so as to protect it or direct the
motions of tlie bistoury while he separated the vagina from the forepart of the
uterus. M.Langenbeck began by making an incision of the perineum from before
backwards ; then divided the vagina backwards, forwards, and upon its sides ;
lastly seized the uterus by its fundus, and completed its detachment by cau-
tious dissection. Dr. Blundell, by detaching the vagina backwards, enters
at once into the recto uterine fossa of the peritoneum, he then seizes the fun-
dus of the uterus with a hook, retroverts it, divides the broad ligaments, and
finishes by its separation from the bladder. Mr. Banner preferred turning the
organ over on its side, after having detached it behind, in front, and off of one
of its broad ligaments, rather than effect its overturn on one of its surfaces.
His operation ended in the section of the remaining ligament. The incision
into the perineum made byLangenbeck, was by Mr. Lizars carried quite into
the rectum ; he then divided the vagina on both surfaces of the diseased organs
before reversing it.
In France, MM. Recamier and Roux have always followed the procedure
of M. Sauter, modified in two particulars. M. Recamier recommends the use
of tractors, such as were previously mentioned, if they can be introduced : or
if this is not possible, the carrying up into the uterus of one brarch of a double
hook forceps, the other branch of which should have three points, and be ap-
plied as high as possible on the exterior face of the neck. If this cannot be
done, he then advises the use of the instruments of Museux, either simple or
jointed like the forceps, bent of Z shape, or only at a right angle, as proposed
by M. Tanchou, at the outer third of their handle, so that they may not too
much conceal parts during the remainder of the operation. With one or
other of these instruments the cancer is to be drawn down as far as possible,
A straight bistoury, guarded by the right hand, serves to detach the vagina from
below upwards from the forepart of the uterus, then to effect the separation
of the matrix itself until we arrive nearly to the peritoneum, which is after-
wards to be opened with a pharyngotome, a convex and probe-pointed bis-
toury, or some cutting instrument. The same bistoury, the probe pointed
one, or better still a curved bistoury, still guarded by the finger and passed
89
706 NEW ELEMENTS OF
in at the peritoneal opening, and carried alternately from left to right, is suffi-
cient to detach entirely the anterior surface of the organ from the bas-fond of
the bladder, and to lay bare the origin of the broad ligaments. The index
finger, passed up above the fallopian tube easily glides upon the posterior sur-
face of the peritoneal reflexion, and permits its being cut from above down-
wards, in all the thickness of the fold to its inferior third; and allows the rest
to be included in a strong ligature. Having done the same thing on the oppo-
site side, M. Recamier finishes the section of the broad ligaments, turns over
the uterus forwards, and detaches it from above downwards from the rectum.
The ligatures employed by M. Recamier, are applied upon the inferior
halves of the peritoneal pinions only, because, according to this surgeon, the
principal vascular branches are here situated. He is even of opinion, more
over, that it would be possible, with a finger in the rectum and another in the
vagina, to discover the uterine artery by its pulsations, and contrived to tie it
in the lower part of the ligament in which it lies. This would constitute a
separate operation, and should be done three or four days before the principal
one is performed. This modification is equally thought very easy of execu-
tion by M. Gendrin ; he considers it as very essential, and accordingly strongly
advocates its adoption. This gentleman also advises successive isolation of
the uterus in all its circumference, and that at the close of the operation, it be
turned on its own axis, and not reversed or turned over. Instead of placing his
ligature below the insertion of the tubes as is done by M. Recamier, M. Taral
on the contrary begins by surrounding with it the whole of the broad liga-
ment, using for this purpose a curved needle, like that of Deschamps, and the
left index finger and thumb, to carry it round. M. Taral, likewise, advocates
the introduction of a- catheter or sound into the bladder, so as to use it, at
the instance of Siebold, as a guide to the vesica during the dissection of
the vagina off the anterior surface of the uterus. Injury to the bladder may
be much oftener avoided, he says, by raising up its fundus before the cutting
instrument with the index and middle fingers, whilst separating the tissues
in that direction, even until the peritoneum itself be opened into, than by
tearing the cellular layer rather than cutting it.
M. Dubled, lastly, is of opinion, that after having got the uterus down as
low as possible, and destroyed its adhesions from one broad ligament to the
other, first before and then backwards, a ligature should be passed below the
roots of the tubes across the lateral ligaments, so as to embrace their two
lower thirds, and to allow of their being cut between the string and gestative
organ, and that then it would be easy to amputate the uterus as far as its
fundus or upper edge, so as to leave the tubes, ovaries, and round ligament,
in situ, and also without necessarily opening the peritoneal cavity. But it is
evident that this method has nothing to do with complete extirpation of the
uterus : and that it is no other than a perfected state of its excision as per-
formed by M. Bellini.
It would be difficult to say which of these methods, so various, is the best
adapted for the purpose ; and more particularly as none have been followed as
yet with complete success; and that those which appeared to be followed by
cures were done by different methods. M. Sauter's patient in whom the
uterus was turned over forwards, lived four months; that of Dr. Blundell,
who lived for a year, was operated on by the posterior reversion. The patient of
OPERATIVE SURGERY. 707
M. Recamier, who remained cured, was operated on after this gentleman's
peculiar method.
The perfecting of this operation, as proposed by MM. Gendrin and Taral,
having as yet been practised on dead bodies only, I shall not here discuss
its advantages, or the objections against it. Moreover, as it will, if ever again
performed, be long reflected upon before it is undertaken, and as it is probable
that each one will feel at liberty to adopt some modification of these modifi-
cations, I should fear to trespass upon the time of my reader, did I dwell
longer upon those I have thus briefly described.
Art. 11. — Vesico-vaginal Fistula,
Vesico-vaginal fistula, notwithstanding the frequency of its occurrence,
the difficulty to which it gives rise, and the disgust which it creates, has
hitherto been subjected to few surgical procedures for its removal. Either
as the result of difficult labors, of ill conducted obstetrical manoeuvres, of
gangrenou-s perforation, of contusion or other traumatic lesions, it is an
affection from which a spontaneous recovery is impossible ; nor does the want
of success which has hitherto attended the attempts that have been made to
relieve it, justify the almost complete silence with which it is passed over by
standard authors. There are several sorts of treatment which may be applied
to it.
1st. Suture. — Suture, which naturally first presents itself to the imagi-
nation, is of such difficult performance, that few surgeons have attempted
it, and in the works which have issued from the Parisian school it is scarcely
alluded to. To attempt to stimulate the edges of a wound which one knows
not how to lay hold of; to bring it together by thread and needles, when there
seemed to be nothing to fasten ; to act upon a movable septum, out of sight
between two reservoirs, on which scarce any hold can be taken ; has always
appeared capable only of inflicting unnecessary pain on the suft'erer, and has
accordingly generally been refrained from. Roonhuysen, who is said by M.
Chelius, to have first advised it, did not put it in practice. If I have under-
stood rightly, it was his nephew who spoke to him about it, and who thinks
that after having quickened the life of the edges of the ulcer, it might be
possible to transfix and approximate them by a quill sharpened to a point.
The success said to have been obtained by the use of sutures by Walter, Fatio,
Schroeger, and others, is not invested with proof so positive as to produce an
entire conviction of its truth. But we can no longer entertain any doubts
of its efficacy. The repeated observations made by M. Noegele, in 1812, give
reason to anticipate success in many cases. Following the footsteps of
the professor of Heidelburg, M. Ehrmann proved its value on a patient
confided to him by M. Flamant; and the essay published by M. Deyber
informs us that he was himself, in conjunction with the latter gentleman,
equally fortunate in the case of a woman whom they treated at Strasburg.
The fistula, which in the first of these cases was very broad, in the other very
narrow, was a long while in cicatrizing after the stitches came away, and
attended with much suppuration ; so that the case did not result from immediate
contact in the parts. In 1828, it was done with a like happy result by M.
Malagodi, of Bologna: while the unfortunate attempts made by M. Roux at
708 NEW fiLtlMENTS OP
La Charite, in 1 829, make neither for nor against it, since the symptoms
which preceded the death of his patient, were not at all such as are naturally
attributable to the introduction of the suture.
Method of Procedure, — The following is the manner in M'hich M. Malagodi
operated. He placed his patient and caused her to be held as in the operation
for stone J carried the index linger with a leather stall into the vagina, and
through the fistula into the bladder; used it as a hook to draw out one of the
lips of the bladder a little towards the vulva, and cut its callous portions
with a straight bistoury; did the same to the other, side of the fistula by
changing hands, and then began to insert the stitch. For this second stage
of the operation M. Malagodi again laid hold of one edge of the wound as
before with the left index-finger ; — conveyed a small crooked needle to near
its posterior extremity at a distance of two lines without ; brought it again by
a circular sweep from the bladder into the vagina so as to make it cross the
vesico-vaginal septuniy and afterwards disengaged it. Another needle fixed
to the other end of the string was also carried through the fistula, and
brought out from the bladder to the vagina to be withdrawn as the first had
been. The surgeon applied a second and third stitch in the same manner,
tied each separately so as to obtain an exact coaptation, and concluded by
cutting them very accurately close to the knot with scissors. A catheter
was kept in the bladder, and the patient confined to her bed. The first and
second day the urine passed entirely by the catheter ; on the third a few drops
were seen to have escaped by the vagina. The two posterior stitches had
perfectly succeeded. That nearest to the urethra had torn through the tis^
sues. It was not thought necessary to begin the operation anew. Repeated
applications of the nitrate of silver at different times completed the cure at
the end of a few weeks. M.Roux thought the twisted preferable to the plain
suture. In order to stimulate the edges of the fistula he employed pincers or
forceps ending in a semi-eliptical flat surface or plate, very much like the
disk of a pair of tongs, one of the halves of which had been removed. When
once the lips of the wound were seized by this instrument, M. Roux easily
cut it away with a straight bistoury, and could have done it equally well with
a pair of long scissors. The stitch was first passed from the vagina through
the left edge of the wound into the bladder by means of a curved needle and
the instrument usual for conveying it. This needle was then drawn out from
the bladder into the vagina through the other side of the fistulous opening;
then withdrawn, carrying with it into the two lips of the Wound a little me-
tallic pin fastened to the end of the string. Three others were afterwards
inserted with similar precautions, after which a loop of one suture, carried
over the first, and crossed over each of the fixed pins successively turn by
turn as is done in the operation for harelip, brought about an approximation
of the ctit surfiices, and completed the twisted suture. Symptoms of inter-
mittent fever, and subsequently of functional derangement of the brain, and
inflammation of the peritoneum and pleura began in a few days to manifest
themselves, and increased to such a degree as on the 12th to destroy the
patient. On opening her body the fistulous opening was found very much
enlarged, between the edges of which not the slightest union had been effected
at any part. But, as M. Roux very judiciously observed, since an inter-
vening acute phlegmasia almost always arrests the progress of cicatrization in
1
OPERATIVE SURGERY. 709
wounds, and even causes it to retrograde when once began, it would be unfair
to conclude from the failure in this that the twisted suture was not adapted
to any case of vesico-vaginal fistula. The method followed by M. Schroeger,
though less ingenious, had notwithstanding a more fortunate issue. Still it
cannot be said to have been crowned with complete success; suture was
thrice practised, and the words of tlie author himself are proof that the patient
did not get entirely well even after the third time. *' I convinced myself,"
says he, " that the wound was all healed but about the space of one line—
of which it had been difficult to pare off the edges. The patient was much
relieved, and I was in hopes of being able to conduct her case to a perfect
cure on a fourth application of the sutures; when indispensable business
compelled her to leave Erlangen."
M. Duges's patient was rather injured than benefited by the suture. A
young girl, who was in my department at La Pitie for a long while, submitted
to the operation, which was performed by M. Robouham ; but according to
what I was told by M. Mondiere, who was a witness to it, unattended with
any marked benefit. It would be useless in me therefore to detail the steps
of their respective proceedings. Unless the fistula is extremely wide it is
not possible to hook in the index-finger on one edge as was done by the sur-
geon at Bologna, nor to seize it with the tong-shaped forceps used by M.
Houx. A longitudinal division alone would answer for the insertion of a
suture after the manner of these two surgeons. Now it is well known that
vesico-vaginal fistulas are for the most part transverse or semilunar slits, with
an anterior concavity between the urethra and the entrance of the ureters into
the bladder. But for the too great complexity of M. Noegele's apparatus it
would assuredly offer a much better chance of success than the preceding
ones, although little better suited than they to any but longitudinal openings.
We must have some more simple contrivance before suture can be generally
adopted. M. Schroeger had reason to congratulate himself on so nearly
curing his patient, and on obtaining so happy a result from his three trials,
considering that he only inflamed the posterior half of the fistula, and that
he passed in his stitches a line or two from the cut edges. Experiments
which I have made on the dead body lead me to believe that we might succeed
better in the following way. I place the patient on a bed or table properly
covered, and of a convenient height. A mattress rolled up is placed under
the abdomen, upon which the woman lies, by which the thighs may be flexed
whilst in this position. An assistant keeps the vagina open by means of a
wide tube (gouttiere) of metal or thin wood. With one cut of straight
scissors I enlarge the fistula backwards for a line or two, do the same to its
anterior angle with a straight bistoury, so as successively to lay hold of each
lip with a good staphyloraphe forceps, and cut away its edge either with straight
scissors or scissors a little curved on their flat surface. The sutures are then
put in three or four lines without the stimulated edges. The forceps answer
instead of the finger and thumb to hold the parts while it is being transfixed
with small needles in the way that is done by MM. Roux and Malagodi.
Everv thread is knotted with the fingers at the bottom of the vagina. If the
orifice be a transverse one, a bistoury curved on its flat side near its point,
and very sharp, carried into the vagina will answer for detracting a selvege
i
710 NEW ELEMENTS OF
or border off of its deep edge kept turned over in another direction, or drawn
down by the assistance of a hook and good forceps.
Procedure of M. Lewziski, — Convinced of the difficulties I have pointed
out, several surgeons have turned their attention to another method of treat-
ment. It was natural that as a first principle, the mind should be pleased
with the idea of bringing back the posterior edge of the fistula towards the
urethra, while the anterior edge was to be turned backwards at the same
time. In a thesis defended in 1802 before the faculty at Paris, M.J.J.
Lewziski endeavored to establish the practice. The instrument which he
recommends is a flat sound slightly curved, pierced with two holes at its
point for the passage of a needle also curved. A stem or spring enclosed in
this canula is employed to push out the needle into the vagina through the
posterior lip of the fistula when the instrument is once passed into the bladder.
When drawn out at the vulva, the needle drags along with it a thread of
which a loop or stitch is made. After several are placed in the same manner,
they are all closed in a knot-tightener to close the vesico -vaginal aperture. '
Sounds, Finces Erignes, or Crotchet Forceps:^ — In 1826, M. LallemaM
published a case of long standing vesico-vaginal fistula, cured by means of an
instrument somewhat analagous to that of M. Lewziski. The apparatus of
the professor of Montpelier is, in fact, composed of 1 st, a large canula about
four inches long ; 2d, a double hook which is made to move by a stem within
the principal instrument, so as to be pushed out and drawn easily back again
into its sheath ; 3d, of a circular plate attached to the other end of the canula
or sound, which in case of need would prevent it from penetrating too deeply
into tlie urethra; 4th, of a tv/isted spring [en Z)o?/(/m), designed to draw
forward the little hooks when once engaged in the posterior lip of the fistula.
Its application is similar to that which I described in speaking of the contri-
vance of M. Lewziski. The sound being passed into the bladder, allows the
hooks to be pushed even into the vagina through the vesico-vaginal septum,
which it is the business of the left index finger to sustain. By the turn of a
screv/ they remain fixed in this position. A ball of lint or of fine linen is
then placed, so as to protect the tissues, between the forepart of the urethra
and the outer plate of the sound ; lastly, the spring is loosed, which thence
forward acts simultaneously by pulling on the posterior lip of the wound
through the medium of the hooks, and by crowding back the inferior wall of
the urethra by means of the circular plate, or of the lint which serves as a
fujcrum for it. By means of mechanism, which it would require too much
time to describe, the trigger of the spring may be graduated so as to produce
a moderate pressure only, but which, however, is sufficient to bring the two
etiges of the opening in contact. For three days M. Lallemand was flattered
with hopes of complete success. On the fourth, a few drops of urine having
escaped per vaginam, it became necessary to remove the instrument, on the
inferior surface of which, four lines in advance of the hooks, a small blackish
* The translator not being- acquainted with any Eng-lish word, which expresses this
species of forceps, beg-s leave to subjoin the meaning of the word erigne, that the nature
of the instrument may be better understood. It is a curved hook, used by surgeons to
remove parts difficult to be taken hold of, and to facilitate their extirpation. They are
either single or double ; and are made with the hooks at one or both extremities. Per-
haps the word crote/iei forceps will convey the idea. The word sonde^ in French signifies
equally a catheter, a probe, and a sound. — Translator.
OPERATIVE SURGERT. Tit
brown spot was observable. The fistula, however, appeared to be considerably
diminished in extent. A new application of the crotchet sound was attempted ;
and this time the adhesion appeared complete. However, some imprudence
which was committed in about ten days again gave rise to a flow of urine
through the vagina. A very small separation only had occurred, and the
surgeon thought it possible to complete by caustic the cure which his in-
strument had so far advanced. He was written to sometime afterwards, that
nothing passed any longer through the fistula, and that the recovery seemed
to be complete. Still, as M. Lallemand does not assert that the cicatrization
of the fistula in this case was perfect, the result is left somewhat doubtful.
Some persons who think themselves well informed about it, are positive that
the patient relapsed into her former condition, and that she came to Paris to
consult other medical practitioners on her case. Besides, as the operation
began and ended with the application of the nitras. argenti. and as this article
alone has in many cases lately been incontestably successful, the statement is
really very far from being as conclusive as at first sight it might be supposed.
An attempt of the same kind was made with this instrument during the year
1829, at the hospital Beaujon. In it, likewise, the hopes of success which once
were entertained were not realized ; and ere long the patient was as much
afflicted as she had been before. The inventor himself seems to have been'
equally frustrated in two attempts which he has since made.
The instrument invented by M. Dupuytren, and which he once used with
success, is a kind of large canula or female sound, which has on its sides two
little operculi, or guards (onglets), which open like wings, or shut entirely,
according as a central stem, shaped like a spring, is drawn out or pushed in,
which controls their motions. It is introduced closed into the bladder. The
operculi once separated and fixed, it is drawn towards the operator as if he
was about to remove the whole ; by preventing it from entering the urethra,
the guards cause it to carry forward along with it the posterior lip of the
fistula, while some lint or linen, placed between the meatus urinarius and
the external plate of the canula, allows it to crowd back the urethra and an-
terior lip of the fistula. This proceeding, which is not attended with the
inconveniences either of tearing or perforating the vesico-vaginal septum,
would certainly claim an undoubted preference over every other, were it
really capable of perfecting a complete co-aptation of the edges of the fistula;
but this is not the case, and I fear that it can be considered only in the light
of an adjuvant to the use of caustic, in itself so very effectual. '
Procedure of M. Laugier. — If the suture is applicable only to the longi-
tudinal fistula, it is evident that transverse ones alone are suitable to the use
of the crotchet sound. With a view to obviate this difficulty I adopt the
method of M. Lallemand to fistula of every sort. M. Laugier constructed
a crotchet forceps, jointed like one of Smellie's forceps, whose form depends
upon the shape of the fistula. If it be for a transverse one, the claws of the
instrument are merely bent on one of its surfaces, so as to be placed one on
the right and one on the left side, and to look directly upwards. On the con-
trary, when for a longitudinal fistula, the two crotchets of each claw must
be parallel to the axis of the body, and the end which sustains them bent on
the edge. The forceps, lastly, should be bent more or less obliquely if the
fistula should happen to assume an intermediate direction. The crotchets of
k
712 NEW ELEMENTS OF
this instrument ought to be very short, says M. Laugier, that they may not
pass through and through the vesico-vaginal septum. They are inserted
from within the vagina, and not the bladder. One branch is first carried
some lines out&ide the fistula previously stimulated; the other is then applied
similarly on the other side ; after which they are approximated by locking the
forceps. To graduate the strength of this approximation, and at pleasure to
increase or lessen its power, a screw crosses the two handles of the instru-
ment, very much as it does in the enterotome of M. Dupuytren. The whole
is protected by lint properly disposed within the vagina, or at least at its orifice.
This plan of M. Laugier's has never yet been practised on the living
female, and though a very ingenious combination, I have my doubts of its.
being of any considerable efficacy. It is difficult to understand how, upon
a part so mobile, hooks can be so fastened for three or four days together, as
to keep the lips of a tolerably wide fistula in adequate approximation. Unless
they pass through the whole thickness of parts, they will slip almost inevita-
bly, tearing with them the vaginal tunic, or else the urine will settle into th^
depression left in the bladder, and not fail to find its way out by the sides of
the instrument. Suppose them to press into the bladder, would not their pas-
sage, which would be enlarged by subsequent suppuration before they could
be withdrawn, be likely to create new fistula rather than to heal the former
one ? Besides, to use them the outline of vesico-vaginal fistula should offer at
each point the same thickness. Now those which are incomparably the
most common, which occupy the end of the bas-fond of the bladder, gene-
rally have the side near the urethra exceedingly thick, and the posterior side
on the contrary very thin. Consequently the anterior claw of the instrument
ought to penetrate to a depth of two or three lines, while the other would be
fixed in a tissue of a line, or a line and a half only in thickness. In longitu-
dinal fistula his hooks would probably effect a partial union only, insomuch
as their edges offer almost always spots of various resistance. Lastly, for
deeper-seated fistulas would not sutures be a more certain measure, and would
its adoption be attended with greater difficulty than this ?
Cauterization. — This, which at first blush might not be supposed very likely
to act otherwise than by creating additional loss of substance, is nevertheless
one of the best methods which have hitherto been resorted to. When pushed
far enough actively to inflame without producing mortification of the tissues,
it induces swelling and intumescence, which contracts and closes, for the
time at least, the aperture which we are desirous of obliterating. After the
subsidence of this engorgement the exudation and the suppuration of parts is
attended with manifest disposition to contraction. It is a method there-
fore which deserves from the practitioner the utmost attention, and is particu-
larly likely to suffice in cases in which the opening is not of any considerable
extent. It may be effected either with the actual cautery, or with the nitrate
of silver, the concentrated acids, and that of the acid nitrate of mercury,
of which M. Dupuytren at first thought, should be laid aside. The red hot
iron has the advantage of being most rapid and energetic in its action. Un-
fortunately it is disposed to form sloughs, and destroy the tissues,' which it is
requisite merely to inflame. The nitrate of silver is generally preferable ;
and the actual cautery should supersede it only in particular cases; for ex-
ample^ such as exceeding callosity of edges, which it is impossible to irritate.
OPERATIVE SURGERV. 71^
A lie reu iiut n on u^Ang decided upon a speculum I... _ ,. The
common speculum "trise" is as good as any other. However, for more per-
fectly protecting the adjacent parts, and to leave nothing exposed but the fistula,
we may use a simple cylindrical speculum pierced on one side. It is scarcely
necessary for me to say that the modifications invented by M. Dubois, M.
Erhmann, &c., whilst they certainly answer the end in view, are really quite
unnecessary. Having introduced this instrument so that the fistula can be
seen, we next carry a stylet at a white heat, or a small bean -shaped cau-
tery iron, into the aperture, being cautious to leave it there for an instant
only, and repeat the cauterization if the first application be not sufficiently
active. M. Delpech, who has been remarkably successful with it, thinks that
the cautery should act only on the vaginal side of the opening, and not on the
vesical ; to save, as he says, loss of substance, and also to bring forcibly into
play the power of contraction ; a remark which should be borne in mind in
any subsequent attempt which may be made.
The speculum is never indispensable when nitrate of silver is employed.
A porte-crayon ought never to be used in cauterizing with this substance. It
then scarcely touches any thing but the internal surfaceof the vagina, leaving
the fistula most commonly wholly untouched. To the end of a common pair
of dressing forceps a piece of the nitrate is fastened by a thread so as to pro-
ject at a right angle from the blades. With this contrivance nothing is easier
than to introduce the caustic into the interior of the fistula, and apply it all
around its circumference ; a ring with a little beak for receiving the caustic,
conducted by the extremity of a finger covered with a leather stall, would do as
well as the forceps. However the operation of cauterization may have been
performed, it is proper to throw up repeated injections into the vagina, and
afterwards to place the patient in a bath. A catheter is to be left in the
bladder, and to remain open at the edge of some utensil placed for the pur-
pose before the vulva, that the urine may escape easily.
The operation is to be repeated after pain and swelling have subsided.
It may be recurred to four, five, or six times, according to the benefit derived,
until the urine have ceased altogether to flow through the vagina. It would
be wrong to suppose, that after a fistula is reduced to a very small diameter,
and seems no longer to improve or contract, it will fail of complete success ;
we need not despair, for in numerous instances it will close at the end of
some weeks although the progress of recovery had appeared to be suspended
for ever. M. Dupuytren seems to have had considerable success by cauteri-
zation either with the actual cautery, or by the use of chemical agents.
The cases are mentioned by M. Sanson, who was an eye witness to them.
Attentive perusal of the case published by M. Malagodi induces \\\t belief
that in this patient also the caustic did more for the cure than the suture ;
and in the other cases in which caustic has been used as accessory, or was
combined with means which were considered as of principal utility, it is very
possible that it alone may have produced the results spoken of.
The oldest method, that which alone is mentioned by M, Boyer, and the only
one which is proper when a radical cure is not attempted, is the method of De-
sault. It consists in fastening a catheter permanently in the bladder, whilst
a cylinder of lint, linen, or better yet of gumelastic, is retained in the vagina,
moderately to stretch the angles of the wound.
90
714 NEW ELEMENTS OF
Desault and Chopart who were for a long time embarrassed by the difficulty
of preserving this catheter immovable, at length succeeded in discovering the
means of doing so. Instead of a double T bandage, on which were attached
the ribands fastened to the extremity of the instrument; instead of uniting
these ribands with the hairs of the vulva, these authors contrived a sort of
truss, the cushion of which came up on the mons veneris, and which had at
this spot a metallic plate, bent like a bow, which is made to descend at plea-
sure over the forepart of the pudendum, and is perforated at its end to
receive the catheter. But it seems an unnecessarily complicated contrivance,
which has no more advantage or steadiness than the linen apparatus employed
by others. Desault and Chopart assert that they have cured several women
with it, and quote one case in particular. Still in this case they leave room
for doubt, by saying that the woman appeared to be cured, and not formally
asserting that she was cured. Months, and even years sometimes must
elapse for a perfect cure to be obtained in this way, and is it not fair
to suppose that the fistula during this time may have got spontaneously
well, as has occurred under other circumstances when no treatment was
practised?
If notwithstanding it is wished to trust to the catheter permanently insert-
ed, it seems proper at least to do away with the foreign body placed after the
manner of Desault in the vagina. This, by dilating the canal, must oppose
a natural obstacle to the contraction of the fistula. In such case an egg-
shaped gumelastic ball, however, would be the best thing to try.
If it is admitted that the fistula is of an incurable nature, all that art can
do is to recommend measures of cleanliness ; the object of which is to pro-
tect the organs against the acridity of the urine, or to receive this fluid in
such a way as that it may inconvenience the patient as little as possible.
For this end, J. L. Petit had constructed an instrument which he called the
*' hole of hell" [trou d'^enfer)^ and which if we believe his representation an-
swered perfectly ; but as he has not described it, it has not been possible to
benefit by it since his time. Fortunately that of Feburier, which is to be had at
most manufacturers of gum elastic, leaves on this head nothing to be desired.
It is a sort of basin of caoutchouc which may be worn at the vulva, and is
prolonged into the vagina; and does not interfere with the woman's walking,
or prevent her following her customary avocations. Mr. Barnes, who in con-
sequence of the frequency of vesico -vaginal fistula among English women,
has had to treat them a number of times, uses a long bottle of elastic gum,
which may be introduced into the vagina, and which has on its anterior sur-
face an aperture in which a sponge is fixed, and which is placed towards the
fistula, so that the urine may enter it little at a time. The patient is
to withdraw it twice or three times a day, squeeze out the fluid by sim-
ple pressure, which by reacting on the sponge completely empties the instru-
ment.
If neither of these instruments can be procured, the only resource which
remains for the woman is to supply their absence by means of fine sponges,
pieces of linen, or silk paper, which are to be changed more or less often
every day,
A plan has recently been suggested by M. Charilly, of causing the patien
to lie semiflexed on her abdomen ; with a view to compel the urine to flo^
OPERATIVE SURGERY. 7\5
pu.t, either through the urethra, the catheter, or a syphon, which might be placed
there and prevent it from gravitating towards the fistula ; but it has the great
objection of failing in its object. Neither could it be endured by most women
for more than a day or two. MM. Sanson and Schroeger have tried it for a
good while, have derived no benefit from it, and have been compelled to aban-
don it by the dread of eschars "on the knees, and elbows, and spines of the ilia,
from long continued pressure.
^rt, 12. — Mecto -vaginal fistula.
The posterior surface of the vagina is like the anterior, liable to be lacerated
during delivery; to be compressed by the child's head, or the branches of the
forceps ; to perforation for gangrene, &c. No operation is necessary when the
solution of continuity comprises only the perineum, so as to produce an
increased size of the vulva ; neither is it called for when the perineum is per-
Corated by the head, elbow, or an inferior extremity of the foetus, provided the
posterior commissure of the vagina and sphincter ani remain unhurt. It is
uncommon for such injuries to have any bad consequences, and recovery
in general ensues without any special treatment. But when the laceration
extends further than this, trenches on the recto-vaginal septum fairly, or when
the sphincter ani is torn through, the aid of surgery is required. The
passage of the greater part of the fecal excretions through the vagina,
render it so disgusting an affection, that it is impossible to avoid seeking
relief from its continuance. The same may be said ot" those cases in which
the recto-vaginal septum is perforated or split up above the sphincter ani
which remains entire, and with or without laceration of the perineum. Though
not very uncommon, this fistula is not as often seen as vesico -vaginal fistulae
are ; doubtless, because the head of the child, or the instruments which accou-
cheurs are occasionally obliged to employ, by rubbing against the parts
behind the pubis, compress the bladder in a more limited space, and on a spot
more salient and irregular than is done on the rectum behind. As they
have moreover a greater tendency to disappear spontaneously than such
as occur in the vesico-vaginal floor, it is very natural that they should
have been much and generally neglected. Ruysch mentions a woman who had
one in the recto-vaginal septum as large as the thumb, which healed without
any operation. A fact nearly similar was mentioned in 1829, by M. Phillippe
de Mortagne. The patient of whom he speaks had. an enormous perforation
which caused a communication of the rectum and the vagina. The most cele-
brated surgeons in the metropolis were consulted on the case; they all replied
that she would probabl y remain incurable, and that they saw no operation which
they could advise to be attempted. Laying his patient on her side, and adopt-
ing measures of cleanliness, constituted the whole of M. Phillippe's treatment.
After enlarging considerably, the fistula began to contract, so surely that it
-iWas completely closed in a few months. The cure, when the case was pub-
lished, was still perfect, no apprehensions seemed warranted of a relapse. An
janalagous case had been published by Sedillot, differing only in so much as
that it was of that kind which Smellie in vain endeavored to cure, and over
'Which M. Noel triumphed by using the twisted suture. Unfortunately the
ri6 NEW ELEMENTS OF
organism will not always lend herself to the wishes of the practitioner, and it
is but too common to see lacerations in this situation continue to defy the
best directed efforts of medical art.
As to the operations to be attempted two different species of this disease
are to be met with. In the one there exists a pure and simple fistula, that is,
perforation, of greater or less extent, in some one part of the recto-vaginal
septum. In the other the laceration comprises at once the sphincter ani, and
the whole, or a part of the perineum. If the perineum is completely torn
through, it resembles in some sort a harelip. If torn only at its posterior
point, the wound after the lapse of some time, cicatrizes at this point, and the
case becomes one of the first kind, in which there is mere fistula of the septum
properly so called. To all these cases the means advised for the treatment
of vesico -vaginal fistula3, are applicable also. Cauterization, for example,
seems often to cure them when they present themselves under the form of
a harelip fissure; In fact, it is generally admitted, that by stimulating in
any way the angles of such a separation, it rarely fails to effect union between
them, at least for an extent of some lines. To try the effect of the nitras argent!,
on this principle, it is only necessary to apply it each time to the farthest por-
tion, or commissure of the solution of continuity. Fistulas, properly so called,
will not, indeed, yield so readily, unless very small ; to them, when very
large, it would be useless almost to attempt the application of caustic, parti-
cularly as the crotchet forceps of M. Laugier will furnish us probably with a
much more efficacious resource. A young woman, who had had it for eight
months, was recently cured of one in fifteen days in my department at La
Pitie, by the use of port wine injections.
Suture. — The operation which first presented itself as suitable for recto-
vaginal fistula, and which at the first glance seems to offer most certainty, is
suture. It is only to be regretted that it is so difficult of application ; and
that, thus far, very few cases can be cited in favor of it. M. Gardien tells us
that it was vainly attempted by M. Dubois; and M. Boyer says, that if every
case in which it had failed had been published, the number known would now
be very considerable ; so that he scarce dares advise its performance. Still,
it has succeeded ; and it is probable that in the end, as it is rendered more
perfect, greater benefit will be derived from it. I therefore think that in
most cases it should be tried.
The first cure known to have been produced by it, is that mentioned by
Saucerotte. The patient labored simultaneously under laceration of the peri-
neum in front of the anus, and perforation of the recto-vaginal septum above
the sphincter.
The operation was thus performed : the surgeon distended the vagina with
a double branch speculum, and passed in at the anus, up the rectum, a species
of wooden director [gorgerette, gorget), the convexity of which he placed
under the fistula to serve as a fulcrum on which his other instruments Were
to move. Having thus gained sight of the aperture, Saucerotte cut away its
edges, partly with a bistoury wrapped round with linen, partly with a kind of
cutting scraper {nigine). The furrier's, or uninterrupted stitch which he
preferred, was applied by means of two crooked needles, one shorter than the
other to begin with, and the longer one for the last. The forceps, or common
needleholder, had been altered a little for the occasion ; that is to say, its
OPERATIVE SURGERY. 7\7
extremity had been so arranged as to allow of the needles being fixed in it
in any direction. M. Saucerotte then carried the first stitch up, with this
instrument, to the level of the upper angle of the irritated fistula, where he
confined his ligature by a piece of diachylon plaster, so as not to be obliged
to make a knot in it. Then, with another needle, he made six spiral or over- ,
cast turns of the suture, going from behind forwards, which he fastened
firmly, by tying either half of his thread on some foreign body. During
several days, he had reason to expect a cure would follow; but the woman
who had had no alvine discharge, was ultimately obliged to strain so violently
to expel the hardened, scybalous, fecal matters which had accumulated in
the rectum, that the suture gave way, and the larger part of the feces escaped
per vaginam. However, M. Saucerotte perceiving that the adhesion was still
perfect at the upper part of the fistula, and the woman being herself anxious
for the reperformance of the operation, renewed his attempt after the lapse of
a month. This time he was cautious to divide the frenum formed by the !
sphincter, so that nothing could interfere with the fecal discharges ; and his \
success was perfect. M. Noel has likewise performed this operation of suture,
in a case very analogous to that of Saucerotte. The woman had, during a
painful labor, suffered laceration of the whole perineum, anus, and a part of
the septum. He employed scissors, to reanimate the edges of this old separa-
tion of parts ; placed his two needles, one at the level of the sphincter, the
other an inch higher up; fastened them by the aid of threads to form the
twisted suture ; then closed the woman's thighs, and encircled them with a
few turns of a bandage, which surrounded them both ; enjoined her to lay on
her back, that the feces in escaping might follow the posterior wall of the
rectum; and after the removal of this second needle, became satisfied of the
complete union effected between the sides of the fissure at this point, but also
in the whole upper extent of the laceration, in which no stitches had been put,
and the lips of which had been approximated only as a consequence of the
closure of the lower portion. This happy result, which was not interrupted,
is a proof, that if Smellie in his cases had been more methodical in his pro-
ceeding he would probably have been equally fortunate. In a case which
has recently been published by Mr. J. Nicol, in England, the operator was
thrice obliged to return to the suture; and he likewise completely succeeded
in his attempt.
Another species, the entero -vaginal fistula, has likewise engaged the anxious
attention of surgeons. A knuckle of the intestinum gracilis, the iliac sig-
moid flexure of the colon, getting into the recto-uterine cavity, may by per-
forating it, ultimately make its way through the upper and back part of the
vagina ^ as in one case was known by Roux, and in another by M. Caza-
Mayor. Two very different operations, both in proceeding and in result,
were invented to remedy this species of affection, which becomes a sort of
artificial anus. M. Roux's patient, a young woman, who had had the fistula
for several years, entered La Charite determined to be freed from it, cost
what it might. The surgeon thought it possible to cure it by seeking the
intestine through the abdominal parietes. His intention, which has been
modified in later years, was to separate the end of the ileum from the vagina
first, then invaginate it with the lower end of the colon, and thus by means
of stitches, re-establish the continuousness of the digestive canal. Never was
k
718 NEW ELfiMENtS OF
bold attempt followed by more disastrous results. The woman died, and on
inspection of the corpse it was seen that the part of the intestine which should
have been placed downwards, was inserted in an opposite direction ! That
of M. Caza-Mayor though to appearance more rational, and less dangerous,
did not completely succeed either; the patient dying suddenly of a pneumo-
nia, at the very time when the surgeon was in hopes of seeing his attempt
crowned with complete success. The instrument which he made use of
resembles in its principle the enterotome of M. Dupuytren. It is a kind of
forceps, each blade of which ends in an oval plate or surface, eight lines long
by four wide ; slightly grooved on the intestinal surface to admit corre-
sponding elevations. One branch being introduced into the vagina by the
fistula as far as into the perforated organ, the other into the rectum to the
level of the first, the oval surfaces come together, bringing into contact the
corresponding sides of the two portions of intestine, so as to produce at the
point of junction a loss of substance, from the absorption of the intervening
septum the result of the compression thus effected. The forceps altogether
is about eight inches long; its branches being jointed in the usual way, leave
between them a space sufficient to contain the entero -vaginal septum and the
perineum ; while a screw which crosses the handles at their base allows of
their action being graduated at pleasure. Things happened in this case as
the operator had anticipated.* The fecal matters partially resumed their
natural route, and every thing led to the belief that the fistula in the vagina
would have closed ere long, when the patient perished, the victim of her own
imprudence. The whole result is doubtless very encouraging ; it is only to
be feared that the results will not all be equally so. It is easily conceivable that
when a hole is effected in the rectum artificially, feces may in a measure pass
through it ; but how is the vaginal orifice to avoid receiving some intestinal
matter, and how is it to be obliterated ? The error made by M. Roux in his
operation, in nowise effects the project of proceeding by the failure of the
attempt; the conception remains what it was before.
When fistulse, opening into the vagina are very near the vulva, they are in
general easily cured if treated like fistula in ano. Two examples were
gleaned at La Charite, in 1829, and I was myself successful by the method,
in the case of a woman 39 years old. operated on at La Pitie in the month
of January last.
Art. 13. — Dystokia — Difficult Delivery.
Operations which are sometimes required for the extraction of the child,
have in every age been the subject of a separate branch of medical science;
and can only be discussed with propriety in works upon obstetrics. It would
here be superfluous for me to enter into all the details which they admit of,
yet as there are among them some which ought not wholly to be omitted, I
proceed briefly to describe the steps in their execution.
Symphyseotomy. — Fern el, Pineau, and several of the older authors, im-
pressed with the belief that the articulations, and even the bones of the pelvis
are susceptible of softening during pregnancy, imagined that benefit would
* The instrument, which was removed on the fifth or sixth day, brought with it on one of its
flat surfaces, the double intestinal layer, sloughed off.
OPERATIVE SURGERY. 719
result from promoting this relaxation in cases of narrowness of the pelvis ; and
tliis might be effected by means of embrocations, poultices, and general and
topical bathing. Certain of our modern writers, proceeding on the vulgar tradi-
tions spoken of bj Riolan and Pare, which assures the people that among many
nations it is customary to fracture the pelvis of little girls soon after birth, to
facilitate in them the process of parturition ; and likewise on the saying of
Galen, when on the subject of the pelvis: "non tantum dilatari, sed et secari
tuto possunt ut internis succurratur," have supposed that this section of
the symphysis must have been known from the very remotest antiquity.
Certainly, Lacourvee, who wrote in 1655, does mention a mis-shapen woman
who died before delivery ; and in whose dead body he separated the pubic
symphysis, with the intention of enlarging the pelvis ; it is true, likewise, that
Plenks, in 1766, did the same thing upon another individual. But it is as
certain notwithstanding, that to no one had it ever occurred to propose it
formally as an operation practicable on the living female, until Sigault, then
only a student, made it the subject of a paper which he read before the Aca-
demy of Surgery in 1768. It is the only safe means which can be resorted
to of preserving the child, under these circumstances ; 1st, where its head is
strongly impacted in the upper strait, or below it; 2d, when the head having
passed the abdominal strait, is arrested by the contraction of tlie perineal
circle : 3d, when the trunk being delivered, the head remains behind in the
pelvic cavity. In these cases it is preferable, even after the death of the
mother, to theCesarian section, for it would be nearly impossible to remove the
foetus alive through the incision in the abdomen.
Metlwd of Operation. — The patient being placed upon an operating table,
or upon a bed, in the manner adopted for applying the forceps, is to have the
lower limbs slightly flexed and held asunder at a proper distance ; one assis-
tant supports her shoulders, two others take possession of the knees ; a fourth
makes tense the integuments over the abomen, and a fifth is selected to hand
the instruments to the operator as he requires them. The surgeon seated or
standing up, or to the right of the patient, or between her legs, armed with a
convex bistoury, makes an incision which is to commence a little above the
symphysis, and be continued as far as the upper surface of the clitoris.
The integuments, previously shaved, and all the soft paits of the mons
veneris, are divided by this cut, which is parallel to the axis of the body, and
as nearly as possible in the centre of tlie articulation. It is well however, in
coming to the lower part, to incline the incision a little to one side between
the summits of the labii majus and minus, and also to separate one of the
roots of the clitoris from the ramus pubis in order to avoid afterwards any
dangerous laceration. The arteries to be tied can be but very small ones,
unless the internal pudic have been divided by an incautious prolongation of
the section into the parts below. Some have advised, that to divide the car-
tilage we should proceed from below upwards; others from above down-
wards; many from behind forwards, or from within outwards; but the
majority recommend that it should be done from before backwards. To
effect this, a bistoury, a scalpel of a shield-like shape {en rondache), the
flexible knife of Aitken, a bistoury with a small button at its extremity, or a
common bistoury, the point of which M. Gardien thinks should be protected
from causing internal organic lesions by the nail of the left index finger,
■ oyp Kppn pmnloved.
720 NEW ELEMENTS OF
• None will dispute the right of every one in such a case to choose for him*
self the instrument to which he is most partial. For my own part I think
that in this, as in every other case, it is to the hand, and not to the instrument
that regard is to be had ; and that the only requisite about the knife is that it
be solid, and very sharp. The surest way is to divide the cartilage from above
downwiirds, £md from the cutaneous towards the pelvic surface of the sym-
physis. The incision should be extended upward for half an inch or an inch
on the linea alba, to avoid injuring the bladder or urethra ; for it has happened
that surgeons at one stroke have gone through both bladder and uterus down
to the head of the foetus. It will always be enough to hold the bistoury at a
few lines from its point with the first two fingers of the left hand, whilst the
cutting is done with the right. The previous introduction of a catheter will
also obviate this risk ; or if not beforehand, at least just before beginning the
second stage of the operation. The bladder is thus emptied, and then the
catheter serves to draw the urethra gently to the right, whilst the incision of the
sub-pubic ligament is slightly inclined to the left. The ligamentous tissue
once divided, increased precaution is necessary; the cutting is done rather
by scratching with the point of the bistoury, which is to be laid aside so soon
as nothing more that is firm or elastic remains to be cut through. Should it so
happen that the cartilage is found to be ossified, there would be so little
chance of obtaining any considerable increase of room, except by sawing
through the articulation as was done by Siebold, that I should prefer to have
recourse to the Cesarian section. If the plan of Desgranges of applying the
saw beyond the symphysis pubis upon the body of the bone be practised, the
operation would be equally dangerous, for it is in the sacro-iliac symphysis,
and not in front, that the difficulty is experienced. No sooner is the separa-
tion of the symphysis effected than the posterior branch of the curved lever,
formed by the os innominatum drawn backwards by its posterior ligaments,
produces a separation of six or twelve lines between the ossa- pubis; the
extent of which will vary according to the degree of contraction in tlie pelvis,
and that of the consistence or softening of the cartilages. Though it is some-
times effected equally at the expense of both bones, it must also sometimes
depend much more', upon one bone than on the other. Be this as it may, I
can scarcely believe it possible that it can of itself grow to such a degree as to
become dangerous ; and that it can be needful to guard against this by con-
fining the hips before the end of the operation, as has been recommended. On
the contrary it is almost always necessary to press upon the spines of the ilia
frgm before backwards, and from within outwards, with slowness and in
moderation; or else to separate the thighs of the female tenderly to carry it
to a sufficient extent.
The delivery being effected, the surgeon wipes the parts, approximates the
pubes one to the other, covers the wound with a rag spread with cerate, some
lint, and a compress, all kept on by means of a bandage round the body ap-
plied sufficiently tight as at least partially to oppose any fresh separation of
the joint. The patient is to lie on her back in a state of perfect immobility.
The thighs at least are in need of the most absolute repose fw six weeks or
two months, which is the time requisite for the reconsolidation of the sym-
physis. She is moreover to be restricted to the regimen suitable after serious
operations ; and the untoward symptoms, if any, which arise are to be met and
OPERATIVE SURGERY. 721
treated with promptitude and energy. As the time for recovery draws near,
walking and motion are to be allowed with the utmost limitation; if there be
still pain, and a degree of mobility in the pelvis, the state of rest is for a cer-
tain time to be resumed. Nothing undoubtedly can be more desirable than
consolidation in the divided symphysis; but women, in whom it could not be
effected, have nevertheless been ableto walk, stand upright, and even to leap,
without any sensible inconvenience; a peculiarity explicable onjy by sup-
posing an acquisition of greater solidity in the posterior articulations. MM.
A. Leroy and Lescure go so far even as to say that this should be encouraged
by dispensing with the bandage round the pelvis ; they assert, and perhaps
not entirely erroneously, that the interpubic space becomes filled up with cel-
lulo-fibrous tissue, which detracts nothing from the resistance of the articula-
tions, and which in the end would have the effect of causing the woman to
lic-in with the greater facility.
The few advantages of, and great danger in symphyseotomy are now so
fully established that it is seldom performed ; and it is really a sort of event
in surgery that M. Stork should have had a successful issue from it in 1829.
Upon the whole, when it is considered that of forty -three women on whom it
has been performed, fourteen have died ; that many have remained cripples
for life, and particularly the two operated on at La Maternite, of whom
Mdme. Lachapelle speaks : that in many it v/as not indispensable, for as may
be seen in the w^ork of Baudelocque, they would have been delivered at a
later period ; that in most of the cases the foetus has not survived, and that
in fact it must perish in most of the cases, owing to turning beino; performed,
ilr to the use of forceps, which it is almost always necessary to attempt ;
lastly, that as Lauverjat has said, out of eighteen ojierations twenty-one per-
sons, mothers and children have lost their lives ; that in two cases it has been
necessary to recur to the Cesarian section ; that five liave been followed by
incontinence of urine, and one by limping; that in thirty-four cases spoken
of by Baudelocque, only eleven children were saved; when 1 say these
dangers are considered, and fairly weighed against the advantages gained
even in the happiest termination of the proceeding, it is difficult to avoid
siding with Desormeaux in the conclusion that section of the pubis is not less
serious than the Cesarian operation, and that its use must be restricted to very
narrow limits indeed.
Procedure of M. Catolica. — If I rightly understood what was said to me
by Professor Vulpes, it would appear that Dr. Catolica of Naples has substi-
tuted for symphyseotomy another operation, which'strictly speaking is merely
a modification of that already proposed by Desgranges of Lyons. Instead
of dividing the cartilage, he advises a section of the body and ramus of the
pubis on either side, to be made between the sub-pubic or thyroid foramina,
as formerly proposed by Aitken. Thus the sacro-iliac symphysis woiild re-
main unharmed ; no danger of wounding either the bladder nor urethra is
incurred; the cellular tissue of the pelvis is scarcely disturbed ; consolida-
tion is easily effected; no abscess, no caries, no fistula, no limping, no peri-
tonitis is to be feared; and a considerable increase of the sacro-pubic
diameter obtained notwithstanding. I know not enough of tiie reasoning of
the author of the plan to warrant me in condemning or approving of it; and
shall rest satisfied with this brief statement until I become possessed of more
91
722 NEW ELEMENTS OF
ample information. I shall only say that some experiment on the dead body,
and some attempts made by Mr. Ashmead, lead me at first sight not wholly
to reject the idea of the professor at Naples.
Abdominal Ulerotomia. — Cesarian Operation. — Hyslerotomia. — Hysterotomo-
kia. — Cesarian Delivery. — Gastro-hysterotomia,
y The name Cesarian section is given to the opening made in the female abdo-
men and uterus, for the purpose of removing thence the foetus when incapable
of passing joer vias naturales. It has been extended also since the time of
Simon to the incision or incisions which it sometimes becomes necessary to
make in the neck of the uterus, with a view of facilitating the passage of the
head of the child.
HisioricaL — Lost, as it were, in the darkness of ages, the history of this
operation none have thus far been able to trace. In the fabulous periods we
are told that an infant, the child of Jupiter, was taken by Mercury from the
womb of Semele, his mother. The Romans said the same of Esculapius, who
was taken from his mother by Apollo whilst she lay upon the funeral pile
which was soon to consume her. Lycus, we are told by Virgil, came thus
into the world. These vague traditions, a passage in Pliny, and some edicts
of the Roman law, lead to the belief that the Cesarian section was in use in
very remote ages. In a work by Mr. Mansfield, of which an extract may be
found in the Bulletin des Sciences, the author has attempted to prove that it
was practised also by the Jews. It is stated in the Talmud, and in the Mis-
chajoth, that a child born by a section of the belly enjoys none of the rights
of primogeniture. Jaschi has described it in his commentary on the Nidda,
and asserts that women on whom it had been performed were not liable to the
forty-days' purifying.
Nothing however exists to prove at all authentically that it was ever prac-
tised on the living subject before the year 1520, unless the case of a certain
lady of Craon, who, according to Goulin, submitted to the section of the abdo-
men in 1424, and with her child survived it, be admitted as accurate. The
ancient Greek and Latin physicians in no way allude to it. Guyde Chauliac,
proceeding on that passage of Pliny which follows, seems first to have de-
scribed it. " Auspicatus, enecta parente, gignuntur, sunt Scipio Africanus,
prior natus, priusque Csesus, Caesomatris utero, dictus, quade causa, Caesariis
appellati, simile modo natus est Manlius qui Carthaginem cum exercitu in-
travit;" and he seems to think it derived its name from Julius Cesar. Others,
on the contrary, contend that it was from the operation that tliis person and
his family derived the appellation. Bayle however has noticed that since the
mother of Cesar, Aurelia, was living when her son invaded Britain, the ac-
count given by Pliny must be rejected as fabulous. The researches of Weid-
mann and Sprengel having failed to throw any additional light on the subject,
we can only admit the etymology of the Cesarian section to be no better
known than its origin.
According to M. Baudelocque himself, the Cesarian section has been twenty-
four times practiced with success since 1750 up to the beginning of the present
century; since which time, exclusive of too cases not admitting of any doubt,
mentioned by Lauverjat, it has been practiced twice at Nantes, by Bacqua.
OPERATIVE SURGERY. 7£3
and upon the same female ; once by M. Le Maisti*e, of Aix; once at Martini-
que, by a Mr. Dariste; once in 1823, at Dahlen, by Vonderfuhr ; again on
the lith of May, 1827, by the surgeons at the hospital at Florence; twice by
Schenck ; once again by Bulk ; once by Graefe ; once by Luch ; once by
Burns : again very recently in the colonies ; so that it is now quite impossible
to deny that some women, at least, may be saved through its intervention.
Yet neither can the danger which attends it be denied. Boerhaave and Boer
were certainly incorrect in the assertion, that scarce one instance of success
occurs in fourteen cases, but it is quite certain that it has been performed
four times in twenty years, at the Maternite in Paris, and that all four patients
died ; that out of seventy-three cases quoted by Baudelocque, death resulted
in forty-two of them ; that forty-five cases out of one hundred and six re-
lated by Sprengel, failed ; and that of the two hundred and thirty-one cases
mentioned by Kellie and Hull, one hundred and twenty-three did notsucceed
in preserving the lives of the women. Thus far it then may be said that one
out of every two cases of Cesarian section has been fatal ; and Tenon was
certainly wrong in his statement, that since the days of Bauhin seventy women
had been operated on at the Hotel Dieu, and recovered. According to
Messrs. S. Cooper and J. Burns, although it has been done fifteen or twenty
times, there is as yet no instance on record of a successful result of the
operation in Great Britain,
Nevertheless, it does not, a priori, appear, how it should be of so terrifying a
nature. The wounds which it is necessary to make through the parietes of the
abdomen is very large, it is true ; yet the parts cut through are by no means
delicate; there are no arteries, no nerves of any size, no important parts to
be avoided. The peritoneum is wounded ; but the viscera are easily pro-
tected. How very common it is to see the most extensive and complicated
wounds of the abdomen, and punctures of every kind occurring; and yet
give rise to slight symptoms, and the patients to get well. Do we not every
day divide the serous membrane of the belly unhesitatingly in patients
affected witli strangulated hernia? Is it the incision into the uterus alone
which is so very dangerous then ? On the contrary, there is every indication
about the organs of feeble irritability; of very little inclination to take on
inflammation ; and the best condition of parts for safe and speedy cicatriza-
tion. Are there not cases on record, and particularly that recently published
by Dr. Frank, of women who have submitted to and recovered from the
Cesarian section, after laceration of the uterus. The wound at first is
very extensive; but soon is reduced to four-sixths, or five-sixths of its length ;
and hemorrhage, when the organ is free to contract, ceases too soon to be
even alarming. Is it not also possible, by means of proper precaution, to
])revent any effusion of the liquor amnii, of blood, and other fluids into the
peritoneum, during and directly after the operation. It would appear from
this, that it is not alone owing to the operation itself, but to some particular
condition of the patient operated on, that hysteriotomy is so fatal ; and I
cannot therefore help thinking, that if it were done as soon as it is positively
indicated, and not after the woman is exhausted by vain efforts ; after the
uterus has become passive, or has taken on incipient inflanmiation, if not
positively phlogosed ; after peritonitis, or enteritis are imminent, or decided;
after life is in short in serious jeopardy, the Cesarian section would not be so
^^^ ♦^mP ^^^ ELEMENTS OF
frequently fatal, as unhappily it has so far proved to be. It is not only to be
practiced on the living females, but is also proper to perform it on the bodies
of such as die undelivered after the seventh month of pregnancy. •
The Roman law, lex regla^ which is attributed to Numa Pompilius, even
then made it incumbent on physicians to open all women who died pregnant,
as a means of preserving citizens for the state. The senate in Venice, to
strengthen this ancient custom, passed a decree in 1608, and 1721, which
subjected practitioners to very severe penalties if they did not operate on the
supposed dead person with all the care which they would have exercised if
she had been living. The king of Sicily enacted another law, by which he
subjected to the punishment of death, such physicians as* should omit to per-
form the Cesarian section on patients who had died in the latter months of
pregnancy. As to the necessity of acting immediately after the death of the
mother, with equal caution as during her life, it will be judged of by recol-
lecting the difficulty of forming any certain opinion as to her actual decease,
and the haste which is then to be exercised. Van Swieten and Baudelocque
relate three cases of women believed to be dead, and who recovered from
their lethargy, just as the operation was to have been performed upon them,
Peu gives another instance, justly much more alarming. He was in the act
of making his incision, when the woman started, ground her teeth, and moved
her lips ! Another equally remarkable, is mentioned by Rigaudaux. He was
sent for two leagues from Douai, to see a poor patient, whose labor gave rise
to the most lively anxiety. Ere he reached her she was supposed to have been
dead two hours. Unwilling to cut into the abdomen without some further ex-
amination, he explored the sexual organs, perceived that the pelvis was an
informed one; passed up his hand to the feet of the child, and delivered it
apparently lifeless; but which by care and attention was recusitated at the
expiration of a couple of hours. As the limbs of the mother preserved their
flexibility, Rigandaux forbid her interment before the abdomen became green.
The woman happily recovered so perfectly in a few hours from her state of
asphyxia, as herself to call on the surgeon four years afterwards, and inform
him of her being still in existence.
When the Cesarian operation was performed after death, the incision was
made always on the left side of the abdomen, " the woman," says Guy de
Chauliac, '* being opened with a razor on her left side, because of the liver,
this side being so much more free than the right." But since it has been
attempted on the living female, better principles govern its performance. Five
methods of proceeding on the part of accoucheurs, among the m^any which
there are, particularly require notice. 1st, That in which the incision is made
along the median line, parallel to the axis of the body ; £d, that in which it is
made outside of the rectus abdominis muscle ; 3d, that in which theparietes
of the abdomen are divided transversely on one side ; 4th, that in which the
wound is situated directly above, and in the direction of the Fallopian liga-
ments ; 5th, that which is performed on a level with the crista of the ileum.
Solayres, Henckel, Deleurye, and others, have erroneously given the credit
of the first of tliese procedures, that of incising on the median line, to Plat-
ner, Guerin, or Varoquier. Mauriceau had previously expressed himself
on tiie subject with great clearness. The majority are in favor of cutting
into liie left side of the abdomen; but, he continues, the opening would be
d
OPERATIVE SURGERY. mlm 725
better made between the recti muscles, for there is nothing but muscles and
integuments to be divided. This metliod — the one to which Baudelocque
gives the preference, that generally pursued in France, Germany, and Eng-
land— by being done on the linea alba, enables us to avoid the muscles, and
to give but little pain : no artery can be wounded, and the uterus moreover
is opened in a direction parallel to its principal fibres. It has also been urged
against it that it incurs the risk of wounding the bladder ; that the flow of fluids
during or after the operation can be effected only with difliculty ; that the
wound, consisting only of fibrous tissues, is slow in healing; and that the
uterus, by being opened in almost the whole extent of its anterior surface,
tends by contracting rather to separate than approximate the lips of the in-
cision into it.
In the lateral operation the older accoucheurs preferred generally the left
side, and made their incision sometimes straight, sometimes slightly oblique ;
and at others of a crescentic shape, but always outside of the rectus muscle.
This method, according to those practitioners who adopt it, has the advantao;e
over the other of shielding the bladder wholly from any accident ; of admit-
ting of easy cicatrization ; and of interfering less with the escape of fluids
which ought to pass out by the wound. As the uterus is almost always bent
a little on its axis by inclining to either the right or left side, it has been
thought that the incision into the median line would fall rather on its left edge
than on the middle o^ its anterior surface. Pursuant to this view it has been
advised to operate on that side to which the uterus naturally inclined. Ad-
mitting the reality of these advantages, they would, I think, be more than
overbalanced by the danger of cutting the epigastric artery, or its branches ;
of producing an opening whose lips could with difliculty be kept in contact,
owing to the retraction of the oblique and transversalis muscles ; and by the
impossibility of obviating the defect in the parallelism with two incisions,
that of the abdomen, and that of the womb.
To avoid the inconveniences connected with these two proceedings, jUiu-
verjat, who at first had thought that hysterotomy in the median line offered great
advantages, endeavored to methodize a plan which had by some physicians
been before practised, and recommends that a transverse incision, five inches
long, be made between the rectus muscle and the spinal column; more or less
below the last false rib, according to the distance of the fundus uteri. Thus,
says he, the fibres of the transversalis are separated rather than cut through ;
the lumbar and epigastric arteries are avoided ; and the fundus uteri come
down upon, whose cavity forms a funnel, so as to render the escape of the
lochia both by the vagina and the wound very easy. Sutures are unneces-
sary, and the parallelism easily preferred. Simple position is sufficient to
keep the edges of the division in exact contact. The outer angle of the
wound having a depending direction, there is incomparably less fear of abdo-
minal effusion than by any other method : but it may be objected that the
fleshy fibres of the great and lesser oblique muscles are necessarily divided ;
that the least effort must expel the viscera; that the uterus is opened at its
fundus where its vessels are largest, speedily retracts from the external aper-
ture, and that the contraction of its fibres ought to hinder, rather than promote
the healing of its cut edges; so that in fact, notwithstanding Lauverjat's two
successful cases, and the seeming preference given to it by M. Sabatier and
726 NEW ELEMENTS OF
M. Gardien, this method evidently is not less dangerous than the two which
preceded it. Fearing above all things injury of the peritoneum and the body
of the uterus, M. Ritgen has advised us, lately, to incise transversely the
attachments of the broad muscles of the abdomen to the crista of the ileum ; to
detach the peritoneum as far as the upper straits, and divide the cervix uteri
to an extent sufficient to admit of the extraction of the foetus. In the first
place, I do not see how it can be possible to divide the summit of the uterus,
"without also dividing the serous membrane which envelopes it; and the other
inherent difficulties in the measure, added to the detachments which must take
place in the fossa iliaca, seem to me such as cannot fail to render this equally
dangerous with any operation previously spoken of. So far as my knowledge
extends, however, it is a mere project; and as yet has never been practised
by any one upon the living female.
The nephew of M. Baudelocque, who attributes the principal dangers which
attend the Cesarian section to the double lesion inflicted on the peritoneum,
and believing wounds of the uterus to be essentially fatal, has proposed a new
method which, in this double respect, seems to him more advisable than any
other; from which indeed it differs very considerably.
The incision begins near the spine of the pubis, extends laterally, parallel
toPoupart's ligament, to a little below the antero-superior spine of the ileum.
He selects the left side on account of the obliquity of the neck, when the
uterus is inclined to the right; the right side in an opposite state of things.
Having divided the Wall of the abdomen, not injuring the epigastric artery,
he pushes back the peritoneum from the fossa iliaca into the pelvic cavity,
and from off the upper part of the vagina, which he then opens. This operation
must be of some extent; and through it the finger is carried to the os uteri,
which it endeavors to draw towards the wound in the abdomen, whilst pres-
sure is made upon the fundus in an opposite direction to favor its reversion.
When we have succeeded in bringing the cervix in opposition with the open-
ing through the parietes of the abdomen, the delivery may be left to the
natural efforts of the uterus, or if absolutely necessary the uterine orifice is
dilated with the fingers, and the foetus removed either by the hand or the
' forceps.
The conception of this operation, called " elytromia" by its inventor, is
certainly highly ingenious. He has made on the dead subject, either pregnant
oi* unimpregnated, many experiments, which have confirmed him in the
favorable opinion he had formed of it ; and which have been of sufficient in-
fluence to cause several practitioners to hesitate in their opinions as to its
importance. Sir C. Bell and Mme. Boivin, fearing hemorrhage more parti-
cularly after the Cesarian operation, had equally felt the necessity of incising
the womb as near its summit or neck as possible, in which spot the fewest
vessels exist. I cannot bring myself to believe that in most cases such an
operation is practicable; or that the laceration of the vagina, combined with
the injury effected in the fossa iliaca and pubic excavation, can be much less
dangerous than the simple straight forward incision through the peritoneum
and uterus, which can be made in performing ordinary hysterotomy. I may
add, that recently M. Baudelocque, junior, has himself been obliged to have
recourse to the Cesarian operation, properly so called, in the case of a woman
he had watched for a good while, after performing on her his " elytromia,"
OPERATIVE SURGERY. 727
and being assisted in the operation by M. Herves de Chegom. 1 Know the
impropriety of drawing sweeping conclusions from a single fact; but the
result of this, the only experiment made on a living female, with me adds
great strength to the apirori opposition offered by reflection to the views of
the author. Another mode of operating, somewhat analogous to that of M.
Ritgen, and not very far removed either from that of M. Baudelocque, seems
to have been suggested about the same period by Dr. Physick. The surgeon,
after observing that in many cases of pregnant women it was easy to separate
the peritoneum from the bladder and from round about the neck of the uterus,
thought that by making a horizontal incision directly above the pubis, the
cervix uteri might be arrived at and opened without any interference with the
serous abdominal membrane. The operation, whatever Dr. W. E. Horner
may say of it, is rather unworthy of its inventor, and not worth dis-
cussing.
Method of Operation. — Never, and if particularly the operation recom-
mended by Mauriceau be followed, should evacuation of bladder and rectum
previous to its being commenced be neglected. The instruments, &c.
required, are a straight and a convex bistoury, a probe-pointed bistoury, for-
ceps, scissors, suture needles, ligatures, quills, strips of adhesive plaster,
little balls, and square cakes of lint. Besides which, pieces of linen spread
with cerate, long square compresses, a bandage to go round the body, large
soft sponges, a syringe, gumelastic tubes in case injections are necessary,
tepid and cold water, vinegar, wine, and eau de Cologne, are equally
requisite.
The patient should lie as much as possible upon the bed to which she is
intended to be confined for the first few days after the operation ; and in as
comfortable a posture as possible. She is to be placed upon her back, her
head genth^ raised, the legs and thighs very slightly flexed ; assistants are
directed to watch over her motions, lest she should make any inconsiderately
under the influence of pain. Two experienced persons are to apply their
hands upon the sides and fundus of the uterus, so that no other part may
slip between its anterior surface and the parietes of the abdomen, and so
that it may make as it were but one substance with this latter part. I
think it is better to apply the bare hands themselves than to place them on
large sponges, as is advised by Drs. Hedenus and Kluge.
The surgeon with the convex bistoury, cuts through the integuments from
about the umbilicus to the pubis, a distance of five or six inches, it not being
necessary, or always possible to make for this purpose the large fold advised
by Levret.
Next he divides in the same manner the subcutaneous tissue, the muscu-
lar aponeurosis and fibres, unless the incision is over the median line ; and
also the cellular tissue. This incision must not be carried too low down
towards the symphysis on account of the nearness of the bladder, and
because the abdominal parietes just here, are usually very thick. It would
be better to extend it above the umbilicus, being careful to pass to the left of
this cicatrix to avoid the umbilical vein, and particularly the anastomosis
which may possibly exist between it and the epigastric vein, which distribu-
tion has of late years been noticed by MM. Mesniere, Clement, and Martin.
728 NEW ELEMENTS OF
Having laid open the peritoneum to an extent sufficient to admit the intro-
duction of the left index finger, on which the instrument is to be conducted,
the wound in the membrane is to be enlarged with a probe-pointed bistoury
until it acquires the same length as the incision in the skin. The uterus is
then laid bare. It is cut through slowly, layer by layer, until we come down
to the surface of the ovum. The assistants are then desired gently to press
down the fundus uteri, by giving it a see-saw motion forward, with a view
To preserve as much length of neck as possible ; or we might follow the
advice of M. Kluge, and hook the finger in the lower angle of the wound in
this organ, to produce, or at any rate favor, a like movement, which in giving
an opportunity to prolong very considerably the section upwards, allows the
cervix to be spared. To avoid wounding the vessels of the placenta, it is
better to finish the incision with a probe-pointed bistoury, than to use the
convex bistoury upon a director. I know of no objection to detaching the
placental mass and its membranes beforehand to some extent with the finger.
Now it is, and not before the operation, that we may perhaps be allowed to
follow the advice of Pianchon, to rupture the membranes high up in tlie
vagina with the fingers, or as is customary in Germany with Siebold's instru-
ment. If, which I think is peferable, the membranes inclosing the ovum are
punctured from the wound, it then becomes necessary for the assistants to be
doubly careful not to permit the abdominal parietes to leave the matrix.
Thus we shall guard against effusion of the waters into the peritoneal cavity,
and do away the tendencies which the intestines have to escape outwardly.
Removal of the foetus is to be effected without delay. When it presents
by the feet, head, or breech, it is removed in that position ; and to aid its exit,
the assistants are desired to press slightly on the sides of the matrix through
the parietes of the abdomen.
; If it be in any other position, the feet must be taken hold of, and the
extraction made with as much precaution as in a natural delivery, being
above all particularly careful not to confound or injure by violence the lips-
of the incision into the uterus.
After the delivery of the foetus, we may follow Pianchon by the assistance
of a gumelastic catheter, bring out the funis through the uterus so as to
deliver the after-birth by the vagina; although no future advantage is gained,
and the operation is materially lengthened by so doing. Besides which the
contraction of the uterus, which most often renders it impossible, soon obliges
the placenta to engage in the wound, indicating thereby the preferable mode
for its extraction, that it may offer less bulk and resistance. It is even better
to take hold of it by the edge when we can do so, than to pull merely on the
cord. Care is to be taken as in a natural delivery to twist the membranes
into a rope, to prevent any from remaining behind in the uterus. If it con-
tain clots of effused blood they must be taken out with the hand. It is also
admissible to wash out the parts with an injection of warm water ; although I
do not think that with a view of keeping open the os uteri, the plug of lint
which Baudelocque recommends, the hollow bougie of Ruleau, the tent
of Rousset, tlie catheter of Tarbe, or any other species of tube whatsoever,
are necessary. They do not prevent closure of the orifice, and would only
increjise the irritation without any counterbalancing good. The intro-
OPERATIVE SURGERY. '729
ductioB of the finger from time to time will serve to open it again if it cease
to transmit fluids, which nothing can prevent from passing wholly or in part
tlirough the wound after all.
The operation being over, the flow of blood is next to be attended to and
arrested. In the lateral procedure, especially in that of Lauverjat, many
small arterial branches may have been divided. These are now to be tied,
unless it lias been thought better to do so during the progress of the opera-
tion as they were successively opened. Whilst the operation is going on the
orifice of the uterine artifices are to be stopped by the fingers of the assist-
ants. Tiiere can be no need of t}4ng them, but it has been advised to caute-
rize them in tlie plugs of vitriol, or more often, to trust the uterine contrac-
tions, which if slow in occuiTing, are to be solicited by stimulating the cavity
of the organ or the wound with the fingers, or with pieces of linen dipped
in vinegar and water.
At the end of a few minutes, the incision is reduced to an extent of only
one or two inches, after which every kind of hemorrhage becomes impossible.
It is usual in England, Germany, and even in France, to unite the wound in
the abdomen by the interrupted or twisted suture, because it is said it is the
only means of keeping the surfaces in contact, and guarding against ventral
hernia. Still we are recommended to do without it by Sabatier, who says, that
unless the sutures were to go through both thicknesses of the abdominal pari-
etes, which would be dangerous, straps of adhesive plaster do quite as well
as stitches, and do not, like them, involve the safety of the patient. I
think it preferable, notwithstanding the reasons assigned by this learned
writer, to employ stitches, even when we have pursued the plan of Lauverjat.
In every case the lower angle of the wound is to be left free, to allow of the
escape of the fluids, and to permit the pledget or tent which has been left in
the uterus to conduct them outwardly. The insertion of stitches moreover
does not prevent the application of adhesive strips between them ; nor do
they interfere with the use of a bandage and favorable position to facilitate the
action of the plasters. The wound is then to be covered with a linen rag
perforated with holes, or with strips spread with cerate. Two large long
compresses are placed on the sides, little cushions of soft lint, common com-
presses, and a bandage well put on around the body, conclude the dressings.
We are before leaving the woman to take from her person the linen which
has been soiled during the operation ; then to carry her as gently as possible
into the middle of her bed, where we try to dispose her so as that every
muscle shall be in a state of relaxation.
An anti-spasmodic draught, containing a gentle opiate to overcome nervous
agitation ; proper precautions for insuring the lochial discharge by the vagina,
and guarding against its effusion into the abdomen; demulcent drinks ; vene-
section, and leeches, if the least inflammatory symptom shows itself:
together with recommending the utmost calmness and tranquillity both of
body and mind, comprise all that can be done by the surgeon for his patient
to save her from the dangers by which she is menaced.
I
Art. 14. — Vaginal liter otomy.
According to authors, verv many causes may require the performance of
92
730 . NEW ELEMENTS OF
this — the vaginal Cesarian operation. Such as are most frequent, are oblitera-
tion, and fibro-cartilaginous induration of the cervix, as in the case of which
Simson speaks, and in that also related by Van Swieten ; violent convulsions,
which threaten the life of the patient, whilst the orifice is too tense and too
imperfectly dilated, to allow of the introduction of the hand into it, as is seen
by the cases of Duboscq and Lambron ; extreme backward obliquity of the
orifice, the head of the child all the while dragging the anterior wall of the
uterus before it as far as the vulva, distending and thinning to a degree which
must end in rupture, unless we hasten, as Lauverjat did, to make an incision
into it. It may be useful also, when the uterus, which had prolapsed from
the pelvis during pregnancy, has never been reduced, and that its neck cannot
be dilated by the fingers, although there be danger in protracting the delivery,
of which circumstantial examples are ftirnished by M. Thenance, Jacomet,
and a surgeon at Vaux, quoted by M. Bodin. It is, however, in cases of
scirrhosity, that it has more especially been proposed, in which, so great is
the resistance offered by the part, that the woman exhausts herself in vain
efforts to accomplish its dilation. Lastly, it would be equally proper to resort
to it, as M. Bodin has endeavored to prove, in case of an arm presenting, and
it was ever really impossible to grope for the t'eet, and no other means left of
avoiding amputation of the member.
The speculum employed by some is unnecessary. With a probe-pointed
bistoury wound round with a strip of linen to about ten or twelve lines of
its point, carried upon the fore finger, the neck is easily reached, unless
it be very far from the axis of the pelvis. If this on the contrary be the case,
the probe-pointed one should be laid aside, and Pott's curved bistoury sub-
stituted for it. One incision in strictness would suffice ; but as it is important
that it should not be too deep, it is better to make several at short distances
from one another. It might at first seem as if the head could not effect a
.passage without enlarging such wounds considerably, almost to carry them
into the body of the uterus, and lacerate the peritoneum. However, no such
thing happens, and they remain most commonly limited in extent with the
thickness of the neck. When they are practised for scirrhous or fibrous
induration, scarcely more than an ounce of blood escapes from the part. It is
in this case that M. Duges, I think justly, recommends the removal of the
diseased parts instead of a mere incision into them. When the anterior
surface of the uterus is divided, without one incision extending quite as far
as the mouth, a straight or convex bistoury, not buttoned at the point, must
be employed for commencing the operation, which is much more delicate in
this than the preceding cases. Too much care cannot be taken to avoid
wounding the presenting part of the child in making the incision. When,
however, the uterus is opened into, the finger becomes a sure director, and on
it the insti'ument may enlarge the incision as far as it is found necessary
without any danger. Let me remark, that less risk is incurred in carrying it
backwards than forwards, on account of the situation of the bladder, and that
moreover it is needless to give it too great an extent.
The wound after delivery rapidly contracts, and often before twelve hours
has elapsed, the cervix resumes its natural position. Should the flow of blood
be too abundant, injections of oxycrate, and the use of a tampon, will generally
arrest it without difficulty ; and cauterization, which by the way is easily
OPERATIVE SURGERY. 731
tried, will in such cases be rarely indispensable. As to the lochia, they
t^.scape either through the os uteri or by the wound ; .and as concerns them,
the woman requires no other attention than that usual after ordinary labor.
All details relative to cephalotomy, the use of crotchets, fillets, forceps, the
operation of turning, &c., being fully entered into in the 2d volume of my
Treatise on Tokology, I do not propose to reinsert them here, particularly as
these are operations which it is exclusively the province of the accoucheur to
perform. 1 have spoken of symphyseotomy, and the Cesarian section, only
because a surgeon is sometimes called on by those who have wholly devoted
themselves to the study of obstetrics to perform them.
CHAPTER V.
THE- URINARY APPARATUS.
SECTION I.
The Operation of cutting for Stone or Lithotomy.
A. In the Male.
The operation for stone which is one of the most ancient in surgery, is also
one of the most important and severe. None, perhaps, has given rise to more
treatises, to more discussions, to more labor of every description. The object
which it has in view is, the extraction of whatever substances may have become
lodged or formed in the bladder by an artificial passage or aperture.
Although the word " taille" (cutting) is a very insignificant one, and not
very scientific either, I shall employ it in preference, nevertheless. The
term " lithotomy" is, in this case, of vicious acceptation ; that of •* cystotomy,"
is no better, since the urethra, and not the bladder is most commonly divided.
The fact, that every one knows what is meant by "la taille," is another very
good reason for its use.
Hippocrates, who does not describe it, nevertheless alludes to it at some
length, and proves that there were in past ages, as there are in the present,
surgeons' errant, whose whole occupation was to perform it.
To the father of medicine it appeared either so dangerous or so unwortny,
that he required from his pupils an oath that they would never perform it;
an oath which, if history may be trusted, was not a useless one ; since some
of the lithotomists of the day, bribed by Tryphorus, the usurper, were im-
moral enough to perform it on the young Antiochus VI, who had no stone,
in such a way as that he died under their hands.
Celsus, the first who has truly described it, endeavors to prove that it was
applicable only to persons at least fifteen years of age. This, it appears, was
the doctrine of the Alexandrians, from whom the materials for his chapter
seem to have been collected ; and this view was also taken of it by most
authors until tiie time of Marianus Santus. Since then both sexes have been
subjected to it, and at all ages. Still, with all the numerous improvements
wliich have been in the method of doing it, and in all that concerns it, it has
732 NEW ELEMENTS Or
always been looked on as so dangerous, that some measure is ever being sug-
gested to render it unnecessary. None of them having answered ; and all
belonging properly to the head of true pathology, we shall not here engage in
their examination.
Neither shall I say any thing in refutation of the strange idea of Dr. Dudon,
who recommends plunging an immense trochar into the bladder through
the hypogastrium, as a means of getting at the stone, inclosing it in a little
bag, and dissolving it in appropriate chemical reagents before its extraction.
To feel all the danger and all the absurdity of such a measure, it requires
only to allude to it. I should not even have done that much, however, if the
inventor had not, to my knowledge, been daring enough to put it in practice
on a living being; and if the man who was himself brave enough to submit
to a second equally fruitless attempt, had not very near fallen a victim to his
credulity. Other practitioners have contrived to break and pound the stone
in the bladder into smaller portions, and in this way to withdraw them from
it by the natural passage.
These trials are ilow made regular methods under different names, and will
be considered hereafter in a separate article.
Diagnosis. — Most persons who labor under stone, experience from time to
time, if not constantly, a dull pain and a sense of weight about the funda-
ment; the pain increases on motion on the receipt of jars, as when the patients
ride on horseback or in a carriage, or when they are compelled to undergo the
least jolting.
The urine deposits a whitish sediment or flaky mucus, sometimes viscid
and ropy. The deposits are likewise sandy and turbid, seeming to be puru-
lent, fetid, and tinged with blood. During its emission it often happens that
the flow is suddenly suspended ; and a very simple change in the position of
the body will allow it again freely to gush forth, as if some valve for a mo-
ment had been placed over the orifice of the urethra. The pain felt in the neck,
sensibly increases as the bladder becomes empty, and particularly immediately
after it is completely so. The extremity of the penis is the seat of a pruritus,
which leads the patient to be constantly rubbing and pulling at it; and whicli
is the reason why great length either of the penis or prepuce is in children a
strong symptom of calculous disease in the bladder. The patient has a fre-
quent desire to urinate ; and some pass from time to time gravel, or sometimes
considerable portions of stone. However, it is not common to see all these
symptoms combined in any one individual ; many have scarcely any one of
them. Again, ipany diseases of the urinary passages present frequently the
reunion of them all. Catarrhus vesicas, for example, may be attended with
all the changes which occur in the urine in cases of calculus. If with it there
exists any irritation in or alteration of the urethral funnel, the pain, the fre-
quent desire to micturate, and friction of the penis, may exist as if a stone
were present. The feeling of weight about the anus equally exists in enlarged
prostate. Hundreds of people have sandy deposits and gravel, who. yet
have not stone. Of all the symptoms, that which seems to be the most con-
clusive, tlie sudden stoppage of urine as it flows when the bladder is not yet
empty, i^ likewise met with under other circumstances. The prostate gland
may produce a fold behind the urethra, capable of creating a mistaken notion
on this point. The same thing would be caused by a fungous tumor, or cere-
broid xnass springing from the bas-fond of the bladder, one of which occurred
OPERATIVE SURGERY. 733
last year at the Hotel Dieu. It would occur with still greater facility even,
if the inferior wall of the urethra were to give rise to any polypous or pedun-
culated mass, one of which was met with by Mr, Samuel Cooper, which should
extend into the neck of the bladder.
. A patient who died at the hospital St. Antoine whilst I was in attendance
there in 1829, presented this peculiar disposition. It had frequently hap-
pened that his urine stopped before the bladder had been emptied. Sounding
failing to convince me of the existence of a stone, I did not think ofjcutting
the man. The uvula vesicae gave origin to a tumor like the fibrous masses
of the uterus in density and structure. The tumor, whose footstalk was very
delicate and much flattened in the course of the urethra, was as large as a
small hen's egg, and when pushed a little forward, closed the urethra with
great exactness like a cork. The proof, moreover, that no one of these signs
is conclusive, is that experienced surgeons have often cut patients in whom
no stone was found ; and they alone, therefore, can never justify the
operation.
Catheterism, — Sounds and bougies not metallic do not answer for the ex-
amination of calculi. Instruments of silver, copper, gold, or platina, are
employed for this purpose. The three latter however which have the merit
of being more sonorous, are rarely made use of; the silver instrument being
generally preferred. Some have also thought that a solid sound, or ordinary
staff, should be substituted for the hollow instrument, because as being more
firm and weighty these stems of metal would allow the calculus to be more
distinctly felt. There are unimportant minutia which a really clever surgeon
should neglect. When the instrument is in the bladder its stylet must be
withdrawn, lest it might mislead our senses by some unexpected friction
against the sheath which contains it. The thumb which is applied over its
orifice, whilst the index and medius fingers hold it behind its rings, must com-
pletely cover it, for if it were permitted to vacillate, the result might be a
vulvular movement producing a noise equally capable of deceiving us. By
following M. Boyer's advice, and plugging it with a cork, &c., this no longer
would be to be feared. "We must be careful to introduce the sound when the
bladder is full of urine ; as in that way we contrive to explore the whole
organ most surely. If the patient lies down, we begin by moving the point
backwards upon the median line to the right and to the left, inclining it with
greater or less force to either side. Then we raise the beak up as high as
possible towards the top of the bladder, powerfully depressing the open ex-
tremity ; after which it is proper to pass the heel (curve) of the instrument
over the neck and parts adjacent, and upon various points in thebas-fond. If
all this is done, and no stone met with, the patient is made to sit down on the
edge of his bed ; or he may be requested to rise and walk a few steps, and
it is also sometimes of use to let him lie first on one side and then on the
other. As a last measure, the surgeon gives exit to the urine, and without
disturbing the instrument waits until the bladder contracts upon itself, so as
to push the calculus towards the urethra, and in contact with the metallic
sound .
In a majority of cases these varied researches will speedily assure us with
certainty that a stone exists ; but only because we do not discover one it is not
certain that a stone is not present. Very small stones sometimes escape the
, 34 NEW ELEMENTS OF
fnanipulatioiis of the most skillful. There are often cavities of such a depth
as that the sound passing above them gives no sensation of encountering a
solid bod J. It is not very uncommon to meet an excavation directly behind
the prostate, either on the right or left side, or in the whole extent of the bas-
fond of the organ in which stones of a certain size easily escape the notice
of the searcher, as the fact which is related by M. Belmas proves. In other
cases the stone is, as it were, pinched between two folds of the urinary blad-
der; it iffey also be fixed in some particular cul-de-sac, whether the mucous
project as a hernia between a separation of the fibres of the bladder, as often
happens in what are called '' vessies a colonnes" (bladders in which there are
fibres resembling tlie columnse carneae of the heart), or whether a true
cyst have formed around the stone as M. Meckel says he has observed. It is
clear that if the foreign body is not quite unconfined at any part of its surface,
sounding will not indicate its presence; and that in the other cases it is only
by the changes made in the position of the patient and the motions of the
sound that we can hope to discover it. It has been thought that when the
difficulty arose from the small size of the stone, or that the friction of the
instrument was too feeble to be accurately perceived, auscultation might be
of some assistance. M. Lisfranc was one of the first who proposed this plan ;
the ear or the stethoscope is applied to different spots on the hypogastric re-
gion with the usual care, while the instrument is manipulated in the bladder
at the same time. This is done with the hope that no sound will escape atten-
tion, and that the slightest echo of the sound as it touches the stone will be
detected by the ear. To render this resort yet more delicate, a young Ame-
rican surgeon, Dr. Ashmead, recollecting that air conducts sound better than
liquids do, conceived the idea of filling the bladder with this fluid. It is not
worth while to deceive oneself about the value of such improvements as
these.
Every time that a sound fairly touches a calculus the surgeon will feel it as
well by his hand as by his ear. I could never advise any one to assert upon
the evidence of auscultation that there existed in the bladder a stone, the
presence of which simple sounding did not otherwise convince him. To re-
turn; the only difficult thing is not to feel or to hear the stone, but to touch
it — to strike it on its bare surface. If in a great many cases the catheter de-
tects no stone, although there are realiy several, cases again occur in whichit
is possible to commit the opposite error. Exostoses behind the pubis — several
of which have been met with by Houstet, Garengeot, Jules Cloquet, Belmas,
and Brodi particularly, who encountered one weighing twenty ounces — and
other osseous tumors which grow from the ischion as is related by M. Damou-
rette, from the sacrum or os coccygis as in the plate given us by M. Haber
in his thesis; an osseous cyst in the thickness of the parietes of the bladder
of which M. ]5oyer's book offers an example; all tliese things have led sur-
geons into error on this subject. The projection of the sacro-vertebral pro-
montory does the same thing. But it is in the texture of the bladder itself
that the commoner causes of error are to be found. I have frequently per-
ceived that in slipping the point of the sound from the median line to one side
there occurs a jerking motion, w^hence results a feeling of resistance or of
inequality, very liable indeed to deceive those who are not aware of this
peculiarity. This is owing to the cavity of the bladder being frequently
i
OPEBATIVE SURGERY. 735
rugous, as is were knobbed ; and to the fibres of its muscular membrane
being almost always gathered into bundles more or less distinct.
Also, it may depend on the presence of masses of a fibrinous, or of any
other character, either free or adherent, which may have been developed upon
its inner surface. If there be any doubt, the operator must not neglect to
introduce one or two fingers of the left hand into the rectum, to lift up the
bas-fond of the bladder, and favor its contact with the instrument as well as
other proceedings usual in sounding. Moreover, we know, that more than
once, the fingers thus situated, aided by pressure with the other hand on the
hypogastrium, have alone been successful in establishing the presence of stone
without the assistance of the sound. These details might appear superfluous
were it not to be recollected that it is proved by innumerable observations,
that immense stones may remain in th« bladder for many years unperceived
by the patient; and that the operation of lithotomy has notwithstanding skill-
ful researches, been practised in other cases upon individuals who had no
stone. Every one knows the history of the monk who bequeathed his body
to the surgeons; so certain was he of having a stone, which none of them
could discover. Lapeyronnie, D'Alembert, the '' taillmr/^* named Portalier,
the watchmaker spoken of by MM. Deschamps, Sabatier, and Richerand, had
each of them an enormous stone in the bladder, of which they gave no evi-
dence nor had any symptom. Another case is mentioned by M. Texier of
this kind, which M. Marjolin in his lectures used to relate; it was necessary
to saw through the pubis to extract it. In Desault's Journal, on the other
hand, we may read the admission of Leblanc, that he had cut a person in
whom there was no stone. Desault himself seems to have committed a similar
error. Mr. Samuel Cooper asserts that he knows of seven instances which
happened to as many difterent surgeons. I can, for my own part, affirm to
four. The first was in one of the provinces ; it was done by a well informed
surgeon, and the patient did perfectly well : the second was done at a Parisian
hospital upon a child who died: the third occurred also in an establishment
in tlie capital : the fourth concerns a young colleague who still lives. Now,
as all these mistakes have been committed by men whose knowledge and skill
cannot be doubted, we may safely be permitted to hesitate before we engage in a
like undertaking. Warned by these dangerous errors, the prudent surgeon
will never decide upon the operation for stone, unless he has carefully
detected the calculus by the sound, not once only, but twice, thrice, or even
more times, if the least doubt exists in his mind after the first examination.
To be more certain still, he should take the precaution to let others perceive
for themselves, what he believes himself to have felt.
On this point, I cannot help mentioning a fact which observation has
established, and one of the most curious of all, viz. that those symptoms
which most often simulate those of calculus, which in Roux*s opinion depend
on some specific irritation of the neck of the bladder, disappear in general
soon after the performance of the operation. Anotlier remarkable thing is,
that these persons recover in much larger proportion than do those who have
really calculus in the bladder; notwithstanding that the numerous manipu-
lations which then become almost necessary, might lead us to infer that the
contrary would be tlie case.
* This word may mean lilhotomist or tailor.
736 NEW ELEMENTS OF
Catheterism, in fact, can indicate to a certain point the state and condition
of the calculi whose existence it detects; their bulk, density, position, fixed-
ness, or mobility. A^hen a stone is felt now at one point, and now at another,
when it glides away on the slightest touch, andwhen after having touched it, it is
difficull to meet with it again, two things are evident; 1st, that it is'entirely
unadherent, and 2d, that its bulk is inconsiderable.
If, on the contrary, it is felt at the neck of the bladder, and the instrument
strikes it in whatever direction it is moved, it follows that it is very large;
unless perhaps it may be fastened on the vesical trigonal space, or at the com-
mencement of the urethra.
The size of a calculus being a very important subject of inquiry, it has
been attempted in all ages to acquire some method of ascertaining it. The
catheter once in the bladder, can, in the hands of a person very much accus-
tomed to its use, give very accurate information upon this particular. To
obtain this the patient must n(l>t move, while the surgeon is to remark atten-
tively the first contact of the two bodies ; then to carry the beak of the sound
from before backwards over the entire surface of the stone, or else to attempt
to hook it in the concavity of the instrument, as if to draw it towards the urethra.
This manoeuvre, when performed in an empty bladder, often succeeds in giv-
ing us a very near approach to the dimensions of the stone.
Surgery has, besides, other means than these of arriving at this result. One
of the best, I think, will be found to be the sound which I have had con-
structed, and of M^iich we shall speak farther on. This instrument is so
arranged, that when introduced, the two halves which compose it, sliding one
over the other, much like the foot measure used by shoemakers, render its beak
an instrument capable of seizing the stone in its grasp, and of determining its
size. The forceps for lithotrity would answer much more surely for this pur-
pose, but they are inconvenient from being straight and more difficult to use.
We are not, however, to expect that with these instruments we shall always
be able to ascertain exactly the size of a calculus. This could only happen if
it were invariably perfectly round, or that we could be sure of having seized
it in the proper position. Now there are flat ones, oval ones, and stones of all
shapes imaginable. The forceps may have hold of them by one angle, or at
one end. They, in turn, may have got too near the roots of the instrument, or
may be held only by their extremities.
A stone may be considered as friable, and of no great cohesiveness, when
the sound emitted on striking it is dull, or that notwithstanding the calculus
appears to be of considerable size it is very feeble. If the collision, on the
other hand, is attended with a clear sound, and the calculus is not displaced
without a certain degree of diificulty, its density must be considerable. When
it Is met with always upon the same side, follows the changes in the position
of the patient, and when after having touched it at one point, the instrument
may be carried all round in the bladder without meeting with another, it is
probably single. If, on the contrary, the sound strikes on a calculus to th^
right and to the left; and if, after having laid the patient on one side, it no
longer meets with any thing in the upper-most part of the bladder; if during
the operation of sounding another collision is heard different from that made
with the first stone; if the staft' successively displaces several mobile bodies,
we may naturally conclude that more than one calculus exists in the bladder.
OPERATIVE SURGERY. 737
Still nothing is easier tlian to err on the subject, and the most accurate re-
searches give at best only probable results, except in some few exceptions,
in which the proof amounts almost to certainty.
It is not easy either to decide on the fixedness or adhesions of vesical cal-
culi. A stone appears to be immovable sometimes because it fills nearly the
whole of the bladder ; at others this appearance is owing to the contraction of
tlie organ; and again, sometimes because of the size of the stone itself: and
also because it is situated in a cavity of greater or less depth, though it may per-
haps be met with soon after in some other place. It may cling by one extremity
to the ureter. This position, which many writers have noticed, is remarkable
in that the stone, though it may be several inches in length, may project
a very little way into the bladder. We may suspect such a case, when the
catheter encounters a sort of point, which nothing can displace, near the neck
and a little outwards towards the base of the trigonal space. We cannot
probably, however, thus distinguish those which are enclosed in pouches, or
abnormal sacs, from those which have really contracted adhesions with some
part of the mucous lining. Of this, as with other diagnostic essays, the same
may be said ; sounding, well performed, will always excite stronger or less
powerful presumption, but never can be attended with absolute certainty.
Nevertheless, if a stone incarcerated by one of its ends iij^ the prostatic por-
tion of the urethra, project by the other into the anterior of the bladder, of
which MM. Le Dran and Blanding each mention an instance, its situation
might be known by carrying a finger up into the rectum, whilst the sound
was kept on the head of the stone. To these particulars we shall return
when speaking of the last stage of lithotomy.
Indications. — Cutting is the only remedy applicable to individuals affected
with urinary calculus, unless lithotrity can be performed in their case. Some
few, it is true, get well without this operation ; others suffer so little frojn the
disease, that to cut them would be worse than imprudent; yet the sponta-
neous disappearance of calculi is so rare, that it should never be calculated
on. It is not uncommon to see them escape through the urethra, unless they
are not larger than a grape seed or of a small kidney bean, in which case it
is sometimes seen. Others, which have made their way by ulceration through
the perineum or the rectum, and thus perforating the tissues, are merely excep-
tions, in themselves almost as dangerous as is the operation itself. The
calculus acting only as being a foreign body, may, when it is enclosed in the
parietes of the bladder, or in small adventitious sacs, cause but very little
suffering to the patient ; and its existence may, under such circumstances, be
compatible not only with life, but with the enjoyment of perfect health.
The facts related by Deschamps and several others, prove also that immense
unattached calculi may exist in the bladder, and yet permit those who have
them to run long careers, and be perfectly well notwithstanding. For all
this, none of these uncommon circumstances in any way weaken the general
rule, and as soon as the presence of stone is conclusively established the idea
of the operation immediately presents itself to the mind.
The size, form, or situation, nor the nature of the stone scarcely ever con-
stitute obstacles to its performance; and the circumstances which contra-
indicates it, are much the same as those of any other great operation. It is
well to state, that catarrhus vesicae, swelling of the prostate, and most
738 NEW ELEMENTS OF
changes in the structure of the bladder, are frequently the results of the pre-
sence of the stone, and that it is common to see them disappear upon its extrac-
tion.
Lastly, a remark which has been already made by a great many authors,
and one which cannot be too often repeated is, that those persons who have
suffered severely from their stone, do, ceteris paribus^ much better after the
operation than those who have scarcely perceived it, or who have only
recently felt the symptoms.
Formerly lithotomy was practised only during the spring of the year. At
this season all the patients with calculi were collected into the hospitals, and
they gathered also in tlie towns, to which the wandering lithotomists flocked
to operate upon them.
This is now no longer the case. Cutting for stone like every other opera-
tion in surgery, is done at every period of the year ; only, as stone is a slow
disease, and that in most cases there is no danger in protracting the operation
for some months, as likewise very hot, or very cold seasons seem rather less
favorable than others to its success, it is still customary to prefer the spring
and fall, when no reason exists for hastening events.
An indispensable precaution to be taken before cutting a patient, is to see
that his urethra is perfectly free. It is a fortunate occurrence, that we are
obliged to do this in spite of ourselves ; for to detect the stone Ave must pass
through the canal. If it be strictured sounding cannot be practised. Care
therefore must be taken to treat this disease by proper means, before litho-
tomy is had recourse to. The other preparations consist of venesection
or of leeches to the anus ; of a low regimen for some days, and a slight pur-
gative to relax the intestines, and guard against sanguinous congestion.
I need not say that if there exist other accessory lesions besides the prin-
cipal affected, they must be combated and wholly removed, before any thing
else is done. Lastly, it should never be neglected to administer on the pre-
ceding evening, or on the morning of the day fixed for the operation, an
injection, so as completely to empty the organ of defecation.
The operation decided on, a great question arises as to the particular man-
ner in which the stone shall be extracted. There are three principal ones,
viz., one which consists in opening the bladder through the perineum ; one
which does it through the rectum, or vagina ; and thirdly, one which attains
the end by going through the hypogastric region into the urinal reservoir.
Art. 1. — Of the cutting through the Perineum {by the lower apparatus).
The method of cutting for the stone through the perineum is the most
ancient of them all. The parts which it is necessary to pass through in per-
forming it, require such exact knowledge of their position and relations, that
it is indispensable for me to point them out acurately before I proceed to any
further details about it.
§ 1 . Anatomical Remarks,
The pelvis ends, as is well known, by an aperture known by the appellation
of lower strait; the form of which is oval, or that of a heart, of which the
OPERATIVE SURGERY 739
larger end is turned backwards. In treating of lithotomy, it is unnecessary
any farther to consider the diameters of this stcait, as is done wlien speaking
of delivery of women. That which extends from one tuber ischii to the
other, is in general not more than about three inches in the male, which length
tapers off insensibly forwards, and is only eight or twelve lines, or less even
near the symphysis of tlie pubis. It diminishes in length equally as we near
the coccyx, but in a much less proportion than in the preceding direction.
Its dimensions may be lessened by numerous anomalies and pathological alte-
rations, to a degree wMch may present an obstacle to the extraction of the
calculus.
Besides the facts of which I spoke as calculated to impose upon a surgeon
for stone, he should also remember that Bonetus saw it so contracted
as scarce to admit the finger ; that in a patient mentioned by Delannay it
was almost entirely closed by the head of the femur ; that the same thing
was effected by an exostosis mentioned by M. Thierry ; by an ossification of
the falciform edge of the sacro-sciatic ligaments described by M. Belmas;
and that Noel of Rheims was also arrested by a similar difficulty in a pelvis
which was shown me by M. Loze. The soft parts which fill up the whole,
are numerous and important. The transverse diameter divides them into two
parts ; the anterior comprising the perineum properly so called, the posterior
forming the anal region. To this, we shall return in our description of the
recto-veislcal operation.
The perineal region, which is represented by a triangle, the base of
which rests upon the fore part of the anus, is divided into two equal parts by
the median line or raphe of the perineum, and its free upper part surmounted
by the scrotum and genital organs.
1. Its Integuments, which are soft and wrinckled, enjoy extreme mobility ;
which renders it necessary to stretch and make them tense when we are
going to divide them. The subcutaneous cellular tissue here is of equal
laxity. As we penetrate deeper it becomes more and more filamentous, and
more loaded with fatty cells ; and even forms on either side, in the cavity
which separates the bulbo-cavernosus (acceleratores urinae) muscles from the
ischio-pubic ramus, a flocculent mass, sometimes of considerable thickness,
and which often becomes the thicker still as it extends backwards between
the ischium and the end of the rectum.
2. The aponeuroses deserve so much the more attention from rae, as
that notwithstanding the numerous researches made into them the descriptions
given of them are as yet very obscure. Nevertheless, in the perineal triangle
they may be easily understood. There are observable two laminae ; the one,
the superficial or inferior, which covers the free surface of the bulbo and
ischio cavernosus muscles [erectores penis) like a thin veil, goes posteriorly
to blend with or lose itself in the other, and thus it remains distinct from the
fascia superficialis, of which many from inadvertence doubtless have con-
sidered it to be an appendage. The second of these two laminae, starting
from the sub-pubic ligament passes back as a septum adhering to the inner lip
of the ramus of the pubis and ischium, and is continuous with the edges of the
sacro-sciatic ligaments. This layer, which has been called by CoUes the tri-
angular ligament of the urethra, and by others the median aponeurosis, is
„ perforated at its posterior part by the membranous portion of the urethra.
r
740 NEW ELEMENTS OF.
At this point it forms a pretty solid barrier betwixt tlie prostate and bulb of
the urethra, and continues itself with the superior pelvic aponeurosis after
having supplied a fibrous expansion to the gland I have just named the pro-
state. This horizontal direction it does not retain in its whole extent.
When it reaches the anal region it bounds or circumscribes an excavation
more than an inch in depth, into which, when a certain method of operation
for the stone which may be called the ischio-rectal is performed, the instrument
is obliged to penetrate. This excavation, which is bounded without by an
aponeurotic layer continuous with the sacro-sciatic ligaments inferiorly, and
by the inner lamina of the fascia-pelvica superiorly, contains within it a
much thinner fibrous lamella, ^nd the exterior surface of the extremity of
the rectum extending backwards on the deep surface of the great gluteus
muscle, it forms anteriorly a slight cul-de-sac above the transversus-perinei
muscle, which is more or less entirely filled up by the cellulo-adipose mass I
mentioned a short distance back.
3. The bidbo-cavernosus muscles, which extend from the point of the sphinc-
ter-ani upon the lower surface and sides of the bulb of the urethra, as well as
the ischio-cavernosus muscles, which embrace each root of the corpus spon-
giosum of the penis, have here no real importance ; unless it be through the
medium of the aponeurosis which separated them from the cellular layer, and
of the triangle of which they are the boundaries ; a triangle whose base dips
down into the ischio-rectal excavation, and which like this excavation is filled
up with filamentous, cellular, or adipose tissue.
The transverse perinei, extending from the ascending ramus of the ischium
in front of the anus, intercrosses with that of the opposite side ; and blending
itself at the same time with the origin of the bulbo-cavernosus and some
fibres of the sphincter-ani externus, it forms below the membranous portion
of the urethra a decussation, a fibro-muscular mass, which is cut through in
almost every operation for stone.
4. The Arteries of the Perineum spring principally from the pudica interna.
The first we have to examine is the inferior hemorrhoidal.
This vessel comes oft' from the primary trunk, and crosses the aponeurosis
very far backwards, so that as it goes almost entirely to the environs of the
anus, its wounds are but little to be feared in the extraction of calculi. The
second is the superfcialis perinei. It arises a little before the tuberosity of
the ischium, and behind the transverse perinei muscle; quits the aponeurosis
directly, dips down to pass below its horizontal portion, and passes forward
as far as into the septum of the dartos, ploughing up the cellular tissue,
and following the ischiobulbus-triangle. In its course, the superficialis artery
is sometimes nearer to, sometimes further from the median line or the integu-
ments. Its size, which is sometimes larger, and its varying position, are
causes why it is often wounded, and why the hemorrhage it affords is in some
patients serious.
The third, or transversa perinei ^ points from the pudic artery, in the thick-
ness of the triangular ligament or horizontal aponeurosis ; tending gradually
downwards and inwards, crosses the muscle of that name, and soon divides
into three branches, one of which goes to the fore part of the anus, the second
to the tissues below the membranous portion of the urethra, the third to the
bulb of tlie urethra itself. Though usually not so large as the artery preced-
OPERATIVE SURGERY. t4l
ing, this vessel is far from always occupying the same place. It is found
sometimes three, four, and even five lines more in advance, and then is dis-
tributed almost entirely to the bulbous and spongy portions of the urethra.
At other times it follows the posterior edge of the transverse muscle so ex-
actly, that at its union with the one on the opposite side it seems a mere arch
in front of the anus.
The Pudic Jirteryy the starting point for all the others, follows a less
variable course. It is to be found supported, as it were, by the pelvic surface
of the outer aponeurotic layer of the ischio-rectal excavation, and of the falci-
form fold which ends the sacro-sciatic ligament in the properly so called peri-
neal region, that is to say, in the pubic arch. It lies betwixt the laminse of
the horizontal or triangular aponeurosis, and so proceeds until it gets
above the root of the penis, where it is lengthened out and takes the name of
arteria dorsalis penis. Thus it will be seen, that in its whole course it is
powerfully protected ; first by the aponeurosis of this region, and again by the
ramus of the ischium and pubis itself, as well as by the edge of the tuber
ischii behind. From its position it can only be got at after all the fibrous
laminae of which we have spoken above are cut through, to do which we must
proceed downwards to a great depth.
Some abnormal arteries have also been met with in the perineal region.
For instance : the hypogastric has been seen by M. Blandin to send oft* the
dorsal branches of the penis, and there to pass up on the side of the neck of
the bladder, and then above the prostate gland to reach their natural situa-
tion. I have myself twice encountered this peculiar distribution, which is
likewise noticed by M. Senn, and which is said by Vesalius, Sylvius, High-
more, Winslow, Burns, Tiedemann, Shaw, and others, not to be uncommon.
x\l though mention of it has been omitted in many modern treatises on anatomy.
Dr. Shaw cites an anomaly more remarkable. Still, and much more dange-
rous, a large artery, given oft* by the hypogastric, at the bottom of the pelvis
extends from below upwards, and from behind forwards, upon the sides of
the prostate, before it passed outwardly. In the operation for stone it was
completely divided, and gave rise to a hemorrhage which nothing could arrest,
and carried off* the patient.
5. The Veins which surround the prostate, and which in old men sometimes
form an abundant and crowded plexus, alone require special notice in
this particular situation. It is unnecessary for more obvious reasons to ex-
amine the nerves and absorbent vessels.
6. The Bulbf and with it a small part of the membranous portion of the
urethra situated between the two fasciae, are separated from the skin only by
a lamellar cellular tissue, not abundant; by the superficial layer of the
aponeurosis ; and the bulbo-cavernosus muscle. From the front of the anus also
it is separated by a space of only eight or ten lines, and sometimes of six
only. Its mobility is sufficient to allow of its being moved to the right side,
or to the left, and at its sides it receives the transversa perinei artery. In a
single case I have seen it extend as far as two lines from the anus, as if to
close the recto -urethral triangle which will soon be mentioned.
7. The Membranous and prostatic portion of the urethra which is to be
found above the horizontal aponeurosis, is enclosed in u space which it is
essential accurately to define. Backwards it is circumscribed by the anterior
T42 NEW ELEMENTS Of
face of the rectum; below by the perineal aponeurosis; above, by the fascia
pelvica; and the space itself is filled up by lax cellular tissue, small venous
trunks, and by small muscles coming off from the pelvis to spread themselves
out on the fore part of the urethra, cal led the muscles of Winslow. The several
objects not being as dense as the tissue traversed by the urethra, the aponeu-
rotic layer which exists on the back part, and appertains to the parietes of the
ischio -rectal excavation, being generally pretty thin, it results from it that that
portion of the urethra which is the least movable, is just that which is en-
closed or strictured in the horizontal fibrous layer of the perineum.
8. 77ie Prostate Gland, which plays so important a part in the different
species of perineal operation for stone, resembles a cone of such ver}^
variable dimensions according to the age and condition of different individuals,
that scarcely any thing decided can be said about it. However, the investi-
gation of several anatomists, M. Senn amongst others, and those in which I
was myself earnestly engaged, allow us as a general rule to say, that its
antero-posterior diameter is from twelve to fifteen lines ; that vertically it
is from ten to twelve lines, and from fifteen lines to eighteen across ; that is
to say, it represents a pyramid whose base, hollowed out, receives the bottom
of the bladder ; whose point extends forwards to the membranous portion
of the urethra ; and whose anterior edge is sometimes deficient to create a
fissure, in which the excretory duct of the urine is lodged. The gland seems
to have developed itself between the mucous membrane and the truly fleshy
portion of the urinary passages ; and is enveloped in a layer, in which I have
often detected fleshy fibres continuous on one side with the median mem-
brane of the bladder, on the other with the evidently muscular layer of the
membranous portion of the urethra, and on a third with the muscles of
Winslow. More outwardly, the gland receives from the perineal aponeurosis
a sheath of greater or less density, which we may call prostatic aponeurosis,
and which as I have said, is continuous with the fascise pelvica ; from the
rectum it is separated merely by a thin layer of cellular tissue, in which fat
is scarcely ever deposited no matter how embonpoint may be the subject.
Its base ascends to about two inches above the anus, while its tip, on the
contrary, inclines from it more or less. In front it is separated from the
sub-pubic ligament by the muscle of Wilson, by cellular tissue, by flakes of
fat, small veins, and by the pubio-prostatic ligaments, which separate the
gland from the pubis for six or eight lines. The urethra which crosses it is
generally nearer on its pubic than its rectal wall ; so much so that M. Amussat
thought it did not completely enclose this canal, but formed merely a groove
for it, itself remaining below. This gentleman's error arose from taking the
exception for the rule. What he asserts as a principle does indeed sometimes
exist; but the contrary is not without proof either. I have in three subjects
seen the urethra in its passage across the prostate, nearer the rectum than to
the pubis. M. Senn mentions having once met with it near the posterior part
of the gland, and M. Tanchou showed me a case in which it is almost entirely
beneath. The following are the dimensions of its different radii, taken at its
base, the interior of the urethra being taken as the centre. The pubic radius
is usually three lines or four long ; the rectal six or eight, the transverse eight to
ten ; and that radius which goes obliquely downwards and outwards ten io
twelve; it being understood that the diameter of the urethra itself enters
into the calculations.
OPERATIVE SURGERY 743
Moreover, the prostate is crossed from behind forwards, and from with-
out a little inwardly, by the ejaculatory duds which open on its summit,
or upon the sides of the verumontanum. The portion of urethra, which like
itself is about twelve or fifteen lines long, and which it embraces, deserves in
turn particular examination. Midway in its lower wall exists a cavity of
more or less depth, as if it were divided into two on the median by the crista
of the urethra. As the verumontanum is the organ to be avoided in cutting
for stone, it is important not to forget its situation. As to the vulvular fold
and the species of sphincter^ of which some persons speak as in this neighbor-
hood, they exercise so little influence over lithotomy that I shall defer any con-
sideration of them until I come to the operations performed on the urethra itself.
The last point, the development of the prostate, is worthy of all surgeons'
attention. Morgagni, Serres, and Sir E. Home, have thought that it was origi-
nally organized in two halves, by two lateral lobes destined after birth to become
blended ; andthatin the adult, a third was added to these two original portions.
In this statement, judging from numerous observations made on the foetus, and
the investigations made by pathological anatomy in the adult, there is a double
error. The prostate gland is formed of a series of glandules, which are developed
simultaneously almost all around the urethra ; and Sir E. Home's third lobe is
nothing but a morbid tumor of the organ. This tumor, which is truly a very
remarkable one, is far from being uniform, and from only appearing on the
median line as the English surgeon asserts. I have met with eight in a single
gland. It is a true pathological production, to appearance like the structure
of the gland, but in reality much of the same nature as the fibrous bodies of
the womb.
9th. The recto-urethral triangle. — Between the rectum and the beginning
of the urethra exists a space through which instruments pass in many species
of operation to reach the bladder. This space of which M. Dupuytren has said
much and with great propriety since 1812, is bounded below by the integu-
ments, backwards by the anterior surface of the termination of the rec-
tum, and before by the membranous portion and commencement of the
spongy portion of the urethra, so that it may be likened to a triangle whose
base would be the skin, and its apex the posterior surface of the point of the
prostate. Going from without toward the bladder, we encounter the sub-
cutaneous cellular layer, the superficial perineal aponeurosis, blending itself
with the base of the horizontal aponeurosis, the origin of the erector penis
muscle, the end of the sphincter, the free portion of tlie bulb of the urethra,
and one of the terminating branches of the transverse perineal artery ; in other
words, the recto-urethral space is filled up by the decussations of the sphinc-
ter ani, the erector-penis and transversus-perinei muscles, as well as by some
branches of the transverse perineal artery, cellular tissue, and the mingling
of the several aponeuroses.
»
p' § 2. Methods of Operation,
Perineal lithotomy has been performed in so many ways, that to analyze the
processes with any advantage, it is indispensable that they should be
collected together in a groupe, and that those v/hich have most analogy be
assembled to constitute so many principal methods.
744 NEW ELEMENTS Ot
In some the stone Is reached without any division of the urethra, while In
others again the furthermost portion of this canal is always laid open by the
instrument. To the first of these it seems correct to refer all that is said
about lateral cutting; the method which seems to me to include the procedures
of the ancients, of frere Jacques, Foubert, and others. The median operation,
or that by the apparatus major oblique, or by the lateralized method of frere
Come, &c., belong to the second genus.
1. Lateral method (Cystotomy properly so called).
a. Procedure of Antyllus, or of Paulus ^ginetus, commonly called appa-
ratus minor.
The description of lithotomy given by Celsus, has until the present time
been the subject of apparently very faulty interpretations. From this it has
resulted that the procedure called methodus Celsianss^ is not in reality his.
For his principles, reference must be made to the Grecian authors. It will,
perhaps, appear from the most extended researches, that it originated in
ancient Egypt ; whilst the true apparatus of Celsus belongs to the Alexandrian
school. In as much as Antyllus has first clearly pointed it out, I think it
proper to name it after this ancient author. To do it the surgeon passes two
fingers into the rectum, and endeavors to hook the stone with them through
the parietes of the bladder ; whilst by pressing with his other hand upon the
hypogastrium, or causing it to be compressed, the descent of it is favored.
Having once seized the stone, he pushes it against the urethra, so as to make
it project between the anus and scrotum, a little to the left of the perineum.
He then with a small knife cuts all the soft parts down to it, in the direction
of a line drawn obliquely from above downwards, and from before backwards,
to the side of the left ischium ; thus he opens the bladder and removes the
stone through the aperture, by pushing it with the fingers he has kept in the
rectum. When the fingers of the operator are insufficient to effect its expul-
sion, a sort of curette furnished with points in its interior is carried into the
wound to hook the stone and bring it out.
This operation, from its great simplicity called apparatus minor, and subse-
quently by the name of the Gmdonian method^ because it had been forgot-
ten until revived by Guy de Chauliac in 1363, was nevertheless described
by a host of authors who preceded the one last named. G. de Salicet, for
example, correctly describes it as Antyllus does ; Paul of Egina, Albucasis,
and most of the Arabian surgeons similarly understood it. Amongst others,
Ali-Ebn-el-Abbas, thus expresses himself as to it, " You shall take the cut-
ting instrument, and you shall cut," says he, " between the anus and the tes-
tes, not on the median part, but directing your excision on the left part of the
thigh. The incision should be oblique, so that the opening may be large and
proportionate to the stone."
A very analagous account of it is given by another author of the same
period. Ebn-el-Coof, of whose work M. Clot, of Abou Zabel, in Egypt, has
translated some fragments. I place this proceeding under the head of lateral
cutting, or cystotomy proper, because in pursuing it we strike generally the
side of the neck of the bladder, and not the urethra or prostate. It is easily
conceivable that the fingers very seldom engage the stone in the prostatic
OPERATIVE SURGERY. 745
portion of the urethra, but that they merely place it in the vesical trigonal
space, and that it is depressed towards the perineum, and laid bare by the cut-
ting instrument through the parietes of the bladder itself.
By examination and operations on the dead body, I have learned that we
then divide skin, cellular tissues, the posterior edges of the transversus
perineal muscle, the superficial and horizontal aponeurosis, as well as the in-
ternal layers of those which cover over the ischio-rectal cavity ; then the left
side of the prostate and the lateral part of the neck of the bladder, vi^ithout
really cutting the urethra; that sometimes the bladder is cut two or three lines
more outwardly, and again, on the contrary, very near the entrance of this
duct; that it is a very easy thing to wound the vesiculae seminales, and also the
anus ; and that in most cases the deepest part of the wound is not parallel
with the superficial part after the operation.
The objections then which lie against this operation, are exclusive of the
difficulty of seizing and hooking the stone with the fingers, of cutting exactly
those tissues which lie over the stone, and of taking it out of so irregular an
aperture; those of dividing the bladder itself outside of the prostate and
thereby exposing to eiFusion into the cellular tissue under the peritoneum to
urinary fistulse, and above all of wounding the vesicular seminales, without
perfectly protecting either the rectum or vessels of the perineum from lesion.
b. Procedure offrere Jacques. — I have said that the method of brother
Jacques (I speak now of that which he originally adopted) belongs to the
lateral operations.
This singular man, who was at first only a servant of Paulini, the Venetian,
and who soon turned monk, wishing to imitate his master, commenced opera-
ting at Besaneon, in the year 1695, and when two years later he came to
Paris recommended to the canons of Notre Dame by many influential persons
as possessing a new method of extracting calculi, went about it as follows. A
cylindrical sound having no groove in it was introduced into the bladder,
and enabled him to press out the neck of this organ on the left side of the
perineum. Brother Jacques then plunged in a long knife between the anus and
tuber ischii from below upwards, or from the skin towards the pelvis pene-
trated into the urinary bladder, enlarged his incision, carrying it obliquely
inwards towards the symphysis pubis, and if it did not appear to him large
enough when his lithotome was withdrawn, he increased it again with a second
knife shaped like an erasure knife ; then he passed in forceps to seek for the
stone, and concluded like Pare, by saying to his patients, *' I have operated
upon you, may God cure you !" Every one must see at once, that by pass-
ing on one side of his catheter, brother Jacques avoided entering the urethra,
and went at once into that portion of the bladder which is protected by the
prostate or a little without the gland. Thus he cut much the same tissues as
the Greek and Arabian physicians, with this dift'erence, that his bistoury
acted on parts regularly stretched ; that he cut partly from within outwards,
instead of acting on an irregular surface such as that of a stone; and that his
incision was necessarily more equal, while its dimensions could be more easily
altered according to circumstances.
The experiments made by the lithotomist Baulot, or as he was yet called
Beulieu, on the cadaver at the Hotel Dieu before Mery, and at La Charite
before Marechal, prove that he was far from always falling on the same parts
94
746 NEW ELEMENTS OF
that in women he often divided the rectum or vagina ; in men the vesicute
seminales ; and aimed particularly at the side of the bladder just where it enters
the prostate to form the urethra. The shoemaker shown himatFontainbleau
by Duchesne, and on whom he operated in the presence of Felix, Bourdelot,
Bessieres, and Fagon, and who in three weeks was walking in the streets,
continued according to F. Collot to have urinary fistula. Of sixty patients
entrusted to him in the two largest hospitals of Paris, only thirteen completely
recovered; twenty-three died, the others remaining with fistulas, wounds of
the rectum, &c., whence I think it follows that his method did not in reality
differ from that of Antyllus, except in the staff which he used, and which
enabled him freely to enter the bladder without the precaution of fixing the
stone firmly against the perineum. As soon as brother Jacques had adopted
the simple modification which was pointed out to him by Mery, Fagon, Du-
verny, and Hunault d' Angers, which consisted in grooving the convexity of
his staff, this method of operation was no longer the same, and from this time
only can be said to be enrolled among the urethra prostatic methods, and to
have become the origin of so many useful improvements. We shall return
to it when on the lateral operation.
c. Procedure of Raw. — If it be true, as S. Albinus asserts, that Raw reached
the side of the bladder without carrying his lithotome along the groove of the
staff, then his method is that of the lateral operation, after frere Jacque's or the
Arabians J but as we have no positive historical facts upon this subject it is
needless to discuss it.
d. The Procedure of Cheselden, — It is very clear that the first procedure of
Mr. Cheselden, the skillful surgeon at St. Thomas's Hospital, belonged to
this category; since he simply laid bare the membranous and prostatic
portions of the urethra, afterwards to divide the parts from behind for-
ward, beginning at the neck of the bladder, and not following the groove in
the staff.
e. TTie Procedure ofFoubert. — The secret so inviolably kept by Raw as to
the mechanism of his method, which after all was probably no other than
that of frere Jacques, at first so violently criticized by him, induced many
surgeons to endeavor to discover a method by which to perform what they
then called lateral cutting, that is to say, cutting by the side of the body
of the bladder. After seeking to attain their end by varying in every possible
way the use of the staff, the length and extent of incision, &c. Foubert at
last hit upon one different in appearance from every other, and which he sup-
posed to be the one performed by Raw.
This surgeon began by filling the bladder with tepid water if the patient
could not contain his urine long enough, passed in a long trocar at some lines
from the tuber ischii, and carried it obliquely upwards, inwards, and for-
wards, into the reservoir of urine. The canula of the instrument instantly
allowing of the escape of some drops of liquid outwardly, added to a want
of resistance offered to the surgeon, served to indicate the entrance of the
trocar into the bladder. This canula then acted as a director for Foubert's
lithotome, which consisted of a bistoury four or five inches long, rather con-
vex, and bent at an angle of twenty or thirty degrees on its cutting side near
the handle. When it had entered the bladder, this knife was carried parallel
to the ischio-pubic ramus, in other words, obliquely from behind forwards.
OPERATIVE SURGERY. 747
and from without inwards, so as to make a wound in the bladder and peri-
neum equal to the supposed dimensions of the stone.
f. M. Thomas, surgeon at La Salpetriere Hospital adopting the same no-
tions, thought it better to pursue another course. He plunged his trocar in
the spot at which Foubert ended his incision, with the intention of dividing
the parts from above downwards, and from within outwards, instead of acting
in the opposite direction as was advised by the inventor of the method.
Moreover, lie finished by transforming into a species of concealed lithotome,
the instrument with which he had effected the puncture, because, said he, the
lithotome thus constructed w^ould allow of giving to the wound a determinate
extent, and greater certainty to the operation. Many patients were operated
on by his method in the Parisian hospitals. It was submitted to tlie test also
in England and in Germany. But it soon became subject to many objections.
Most patients cannot retain their urine, and the injections however mild
they may be, are always painful when carried to such a point as to distend
the bladder.
The direction of the pelvic axis, and the deep situation of the urinal reser-
voir, do not permit of blindly passing a trocar through the perineum without
danger. Nothing could be easier, in such a case, than to stray aside, back-
ward or forward, so as to wound the rectum, vesiculae seminales, ureters,
the peritoneum itself, or to enter the bladder too high up in its body.
To all these undisputed risks one other must be added, which now alone
could suffice to cause the method of Foubert to be rejected, could it ever be
reproduced. It is, that the end aimed at is an extremely pernicious one.
The incision into the bladder being to be made outside of, and above the pros-
tate, between the peritoneum and fascia pelvica, it follows that the least drop
of urine which should be effused at the bottom of the wound might give rise to
inflammation of the cellular layer which clothes the pelvic excavation, and be
speedily fatal.
It will be seen, that in the transverse or lateral operation nearly the same
elements are passed through as in the procedures of Antyllus, Guy de Chau-
liac, and of brother Jacques ; only that it inclines a little to the side, and
that therefore it is perhaps rather more liable to give rise to incurable fistulas,
or to endanger the ureters or vesiculae seminales. The mode proposed by
Pallucci, of previously dividing the perineal layers, so as to allow the fore-
finger to detect the fluctuation in the bladder before it is punctured by the
trocar, does not remedy the least even of these inconveniences.
Nor would the ingenious instrument invented by Lecat answer better,
which is introduced closed, and in opening stretches the bladder at the bas-
fondj and thus renders the introduction of the principal instrument more easy.
2. Median Operation for the Stone. — /Ipparatus Major,
Those procedures in which the incision comprises the greater or less part
of the urethra, being in truth the only ones which ought to be adopted in cut-
ting below the pubis, have likewise engaged more of surgeons' attention.
Among them will be found the median operation by the apparatus -major ; the
lateral operation, or perfected jnethod of brother Jacques; the transverse
operation, and all their modifications
748 NEW ELEMENTS OF
a. Procedure of Mariano. — As the method called that of Guy de Chauliac,
had alone been recommended by the ancients, and did not appear calculated
for any but young subjects, it was not possible that lithotomists should not
have thought of some other.
That which, owing to the great number of instruments it requires, is called
the *' apparatus-major,'^'^ remained for a long time a family secret. It appears
to have been invented by some of the inhabitants of ancient Italian Norcia, who,
under the common title of Norcini, acquired great reputation as operators
during the 14th and 15th centuries. If M. Bonino, however, is correct, and
the archives of Turin prove that its real inventor was Battista di Rapallo, who
died in 1510, the master of Giovani. Be this as it may, Giovani de Romani is
the first to whom history refers it ; and it was published by his friend Mariano
Santo about 1520 or 1530. It was probably known to A. Benedetti ; for, after
announcing that certain calculi may be extracted without a bloody operation,
he says, *' nunc inter anum et cutem, recta plaga, cervicem vesica incidunt."
It was raised to celebrity by the success of Laurent Collot, to whom it had
been taught by Octavius Davilla, and who, owing to this, was appointed litho-
tomist to the court of Henry II. At this period of time the apparatus -major
was still a secret to the public. Philip Collot and Restitut Giraud, who suc-
ceeded their relation, succeeded so ill in instructing ten students by order of
the government, that their children would have alone retained it until Francis
Collot had thought fit to publish the steps of the operation, had not the pupils
of La Charite and the Hotel Dieu thought of making a hole in the floor of the
operating room, and by watching their proceedings, discovered the secret.
It consists in the following process : A grooved statf carried into the blad-
der allows the perineum to be depressed a little to the left of the raphe, and
not as Heister states exactly on the median line. With a lithotome, like an
immense lancet, the surgeon makes his incision into the skin, the cellular tis-
sue, and the muscles, from the root of the scrotum to some lines from the
anus, and which incision crosses the bulb of the urethra, and so strikes upon
the groove into the staff. A director (a sort of stem, formed of a male and a
female branch, differing from one another in as much as that the first ends by
a rather flat and smooth extremity, whilst the other is forked in the same
direction) is then carried instead of the lithotome quite into the bladder.
The staff, now useless, is forthwith drawn out. The female branch of the
director, which until now remains outside, is then slipped by the assistance of
its bifurcation upon the square edge of the male branch into the interior of
the urinary pouch. Fixed thus one upon the other, the two branches of this
instrument allowed the surgeon to dilate the wound, by separating them with
their outer ends, which terminated in a cross to render manipulation more
easy ; but their principal use was to direct the forceps in seizing the stone.
Moreover, a common gorget, and even another instrument called a dilator,
formed of two branches jointed like scissors, which were introduced closed,
and opened by pressing on the rings affixed to their handles, were substituted
occasionally for the one before mentioned.
The apparatus -major, practised by following to the letter the instructions
given by Mariano Santo, is one of the very worst operations which has ever been
invented. The incision, evidently, only bore upon the spongy portion, or at
most upon the membranous portion of the urethra. The dilators could only
OPERATIVE SURGEKV. 749
widen the wound by lacerating the prostate. The urethra itself was some-
times burst entirely, and the rents extended even as far sometimes as the
neck of the bladder and vesiculae seminal es. Bruising the verumontanum,
tearing the ejaculatory canals, bring with it fistula, incontinence of urine,
swelling of the testicles, and even impotency frequently. The external inci-
sion prolonged too much in front, facilitated infiltration of blood, pus, or
urine into the scrotum; and the bottom of the wound, moreover, became in
many a starting place for purulent deposits, which passed in the direction
either of the pelvis, around the rectum, or on the upper parts of the tliighs.
Altogether the operation was so excessively painful and dangerous to such a
degree, that according to the statement of the editor of the works of F. Collot
himself, it was scarcely possible to save one third, or half of the patients who
had the courage to undergo it.
However, it would be unjust to attribute to the apparatus -major all the
reproaches which, from the detail just given of the steps in it, it may seem to
deserve. It had in fact undergone many changes in the hands of different
operators. For instance, since tlie time of Dionis and LaCharriere, the con-
ductor and dilator were used no longer ; after freely incising the urethra
they merely conducted a gorget upon the groove of the staff to beyond the
neck of the bladder, which gorget afterwards served as a guide to the common
forceps. It had been still further simplified by the surgeon-in-chief of La
Charite, M. Marechal. After making his first incision like Collot, he passed
in his lithotome with a complicated see-saw motion to the bladder, perfomiing
what was called by surgeons at that day the " coup de maitre,^^ in such a way
as to divide the whole thickness nearly of the prostate in its posterior radius,
D. Scacclii and C. De Solingen had before formally advised cutting all those
parts which Mariano Sarto preferred to tear. It is evident that in this wav
Marechal cut the bulbous part, tlie membranous and prostatic portions
of the urethra, and consequently that he had an aperture of eight or ten lines
in the neck of the bladder which would allow of the easy passage of bulky
stones without the slightest rupture. This surgeon obtained numerous suc-
cessful results, and concluded his operations with wonderful celerity. Dila-
tation with the finger, as mentioned by De la Faye, had certainly been less
formidable than the instruments of Giovani, but could not compare with the
modification of Marechal.
b. Procedure of Vacca. — Regarded in this light, the apparatus-major had so
lost its terrors that a surgeon of eminence has, in later years, reintroduced it
as a method of his own invention. After for a long while extolling and prac-
tising the recto-vesical operation, Vacca Berlinghieri at last replaced it by a
procedure which differs but little from that of Mery. The Tuscan surgeon
makes his incision upon the median line as did Mariano, comes down to the
membranous part of the urethra with a common bistoury, then inserts in the
groove of the staff the beak of his " bistoury lithotome," which he pushes
into the bladder, and lastly draws it from within this organ outwards, raising
his wrist so as to divide the prostates as extensively as may be wished.
Auotlier alteration of the median operation is contained in a thesis defended
at the commencement of this century by M. Treyheram. The urethra is
opened, and also the prostate, from before backwards ; a dry carrot is then
placed every morning in the bladder through the wound, and the stone only
750 NEW ELEMENTS OF
extracted at the end of some days. The writer states that M. Guerin of Bor-
deaux, the inventor, has obtained from it the happiest success ; and the papers
of the country have again recently taken notice of it. The median method
of cutting for stone, when reduced to its greatest simplicity, offers but one
indisputable advantage, that of not giving rise to any danger from hemorrhage.
Vacca, who in addition to this assigns to it the merit of allowing the stone to
be extracted in the widest point of the lower strait, could never have con-
sidered of his assertion; for in this respect it offers nothing more than a
host of other procedures belonging to lateralized cutting. As improved by
Mery and by Vacca it is less painful, more reasonable, and in every point
of view infinitely superior to the old plan as it came from the hands of
Mariano ; but it is not the less of all the most threatening to the rectum, and
does not guard against wounding the ejaculatory ducts. Moreover, as it
divides the prostate from before backwards in the direction of one of the
smallest radii of the gland, it is not really worthy of the eulogiums recently
lavished upon it by the professor of Piso and his countryman M. Balardini.
S. Oblique t or Lateralized Operation for Stone,
Owing to a mal a propos confusion between the operation described in the
works of Celsus, with that which is described by Paulus of Egina, and An-
tyllus, the lateral method as first performed by brother Jacques has ultimately
been confounded with the lateralized mode of cutting on which so much labor
has since been bestowed. A great difference exists between the modes of
performing them. In one, the principal object in the incision is to reach the side
of the neck of the bladder without necessarily involving the urethra; in the
other, on the contrary, the posterior portion of this canal is always divided,
whilst the bladder itself may be most strictly avoided. The lateralized
method consisting essentially in an incision of greater or lesser obliquity into
the prostatic portion of the urethra, including in it a greater or less extent of
the membranous portion of the same passage, the only procedures evidently
whiich belong under its head are those in which the operator employs a grooved
staff to direct his cutting instrument into the urinary bladder.
a. Procedure of Franco, or of d^Hunault. — So little is the conception of the
oblique method, the right of frere Jacques, that this monk attained to it only
as a consequence of the representations of his antagonists, and after it had
been neatly set forth by Franco and Fabricius Hildanus. Franco says dis-
tinctly, that to incise the perineum in lithotomy, a curved, grooved staff must
be introduced previously into the bladder ; that this staff must act as a
director to the bistoury, and that the neck of the bladder should be divided
obliquely from within outwards towards the ischium. True, he wishe!§ it to
be made on the right side ; but rt is possible that by this expression he means
the right side of the surgeon, which corresponds with the patient's left side.
G. Fabricius evidently followed the same advice previously also given by A.
de la Croix. It is to Hunault of Angers notwithstanding, that we owe our
knowledge on this subject. Plates which he caused to be executed, but which
were never published, show that with a grooved staff we may always cut with
certainty the same parts, and it was in consequence of having adopted his
counsels that brother Jacques succeeded in 1701 in cutting thirty-eight pa-
OPERATIVE SURGERY. 751
tients with stone at Versailles without the loss of a single one, and also the
twentj-two persons collected by the Marechal de Lorges at his hotel in 1703,
that he obtained such brilliant success in Holland, and afterwards on his
return to France.*
b. Procedure of Garengeot and Per diet. — Garengeot — who made the disco-
very during the course of some examinations which he was making on the
dead body with Perchet, a surgeon at La Charite, and who put it in practice
upon a child nine years and a half old, in the year 1729, whilst Morand had
gone to England to teach it to Mr. Cheselden — is the first who seems to have
re-established it upon the grounds first laid down by Hunault. The staff
introduced into the bladder is entrusted to an assistant, who presses it upon
the left side of the perineum to make it bulge in that direction. The surgeon
makes an oblique incision from the raphe towards the middle of the space
which lies between the ischium and the anal aperture with a common bistoury
or lithotome. This cut, which should begin an inch above the anus, goes
through skin and sub-cutaneous tissue. The left index-finger then serves as
a guide to the cutting instrument, whilst the other tissues are layer by layer
divided, and the urethra laid open. The lithotome slipped from before back-
wards, and from above downward, upon the groove of the staff* enters the
bladder, crossing obliquely the prostate outwardly from right to left; after
which the surgeon makes use of it for enlarging the wound by withdrawing
and pressing upon it with more or less strength. With a view to favor its
entrance, as soon as the membranous portion of the urethra is opened, the
operator requests his assistant to lower the handle of the staff, or he does it
nimself, so as to raise the concavity behind the pubis, whilst at the same time
he inclines the wrist of the right hand a little downwards. In this way he
runs no risk of straying, and the bladder is in no danger whatever of being
wounded.
c. Procedure of Cheselden. — Morand in his description of the process
of Cheselden has given nearly a similar idea of lateralized cutting as had
Garengeot, save that it would seem that his principal intention was, after
dividing the prostate, to spare as much as possible the other tissues, and to
make his wound resemble a sort of oblique canal from behind forward, and
from the bladder towards the perineum. But Cheselden has several times
modified his method of operating. His first method I have already described
when speaking of lateral operation, and the second is that described by Morand.
The third at which he stopped is very diff'erent from the notion generally
entertained in France. The English surgeon in every case extends his ex-
ternal incision to a length of two to four inches, and it always fell betwixt
the bulbo-cavernosus and ischio-cavernosus muscles, so as to lay bare the ure-
thra to the summit of the prostate.
The second stage of his operation comprised the incision of the deeper
seated parts, which the former had denuded. To accomplish it Cheselden
* Sabatier is In error in saying that brother Jacques died in 1713. Having" arrived at
L'Etendonne from Rome, or, according to Norman, at his village, Arbagne, in June, 1714,
he went to pass several months at Besancon, and then lived long enough among the
Benedictines to build there a small house, which he afterwards quitted to go and live
with his triend L. Decart, where he died aged 69 years ; and as he was born in 1651, of
course in the vear 1720.
759. NEW ELEMENTS OF
pushed forcibly the anus backwards and to the right side, by introducing the
forefinger of his left hand into the hinder angle of the wound, then on the
nail of this finger passed in a slightly concave bistoury, following the ante-
rior face of the rectum up to the neck of the bladder, struck upon the groove
of the staff" to divide the whole extent of the prostate gland from behind for-
wards, and from below up, by drawing towards him his lithotomc, with its
cutting edge turned towards the pubic articulation.
This procedure of Cheselden's will be seen to be quite distinct from the
oblique or lateral operation for stone, as practised by French surgeons.
It encounters, it is true, the same parts as that of Garengeot; yet, while it
bears the semblance of more perfectly protecting the rectum from injury,
adds in reality to the difficulty of manipulation.
d. Boudou, who performed the lateralized operation, perhaps before ever
it had been described by any one in Paris, adopted a method which differed
from that of Mery, only in the direction which he gave his incision. De La
Faye states in his addenda to the Treatise of Dionis, that Boudou caused the
handle of his staff* to lean towards the right groin, and that after having cut
into the membranous portion of the urethra, he plunged his lithotome along
the groove of the staff', then raised up towards the pubis beyond the neck,
and divided the prostate obliquely to the left, drawing the cutting instru-
ment towards himself.
e. Procedure of Le Bran. — Le Dran one of the most learned practitioners
of the age, had also his own particular method of operating. When he had
cut into the urethra, he introduced a thick grooved sound into the bladder,
immediately withdrew the catheter, and ended by dividing the prostate with
a convex bistoury *' en rondache, shield-shaped," which was about six lines
in width. Notwithstanding that it is insignificant in itself and fitter to com-
plicate than simplify the operation, this modification has had its partisans;
and even now has some still in Great Britain. Allan Burns, for instance,
adopts the principle, preferring however the common lithotome or bistoury to
the instrument of Le Dran. Mr. J. Bell, who Avas of the same opinion,
incises from the prostate towards the first opening of the urethra, as Chesel-
den did, instead of following Le Dran, and carrying the bistoury from before
backwards; and Allan who, like his countrymen also carries in the bis-
toury to the staff* passing behind the prostate, prefers withdrawing them both
together, keeping the two instruments firm one on the other, as is commonly
done in operating for fistula in ano. It is difficult to discover in what respect
the cutting for stone is rendered less dangerous or more convenient by
either of the above shades of diff'erence from the principal operation.
f. Procedure of Lecat. A method of operating for stone, in the oblique or
lateralized way, which at the time made some impression on the profession,
is that of Lecat. The sound used by this operator did not terminate at its
straight end by the usual flat surface, but by a handle. The instrument with
which he laid bare and incised the urethra had lateral notches near its back,
and was called by the inventor his ** uretrome." Lecat conveyed another
one, ending in a blunt extremity, to the assistance of the former as far as the
groove in the staff* to cut through the prostate, very much as was done by
Cheselden in his second procedure,or that described by Morand. However,
the edge of this second instrument, called cystotome, was never to go beyond
OPERATIVr. SURGERY, 75'3
the vesical tubercle which exists at the entrance of the urethra, for which
very reason the name of cjstotome, is most singularly inappropriate to it.
Lastly, the surgeon of Rouen, for a short space conceived the idea of substi-
tuting a sheathed lithotome in place of his cystotome, and to wliich he gave the
appellation o. cystotome gorget. The original which he adopted was a large
incision externally, a small one within; whence we see that he foresaw the
danger of going beyond the limits of the prostate, and preferred rather to
dilate the entrance of the bladder than to incise it. But to accomplish the
ends aimed at beneath the thought, the instrumental apparatus was unneces-
sary, and his method, although he derived indisputable success from it,
was not generally adopted. Some practitioners indeed have continued
to pursue it. Pouteau reaped such successful results from it with a very
slight modification, that in some of the Lyonese hospitals it is still frequently
practised. A surgeon of Venice, M. Paiola, who has increased its complex-
ity, by adding a third instrument to those of Lecat, has it is said recurred to
it five hundred times and never lost a single patient ! This assertion is so
strange that but for Langenbeck speaking in eulogistic terms of its author it
would be undeserving the least attention. It will be seen in a thesis by M.
Dumont, that in the hospital at Rouen, M. Flaubert, also follows the axiom
established by Lecat, and that according to him a small incision and a free
dilation, is a maxim from which no surgeon should ever deviate. M. Delpech
was equally of opinion that it was safer to dilate, and even to tear the neck of
the bladder, than to cut it freely, and that the precept of Lecat on this sub-
ject ought to be law. Beneath it there is an important truth which of late
years only could have been properly estimated, because until then the anato-
mical reason had not been distinctly shown ; it is, that lithotomy confined to
the circle of the prostate is infinitely less dangerous than that in which the
incisions exceed the limits of this gland.
g. Procedure of Moreau. A surgeon at the Hotel Dieu, in Paris, M.
Moreau, who died in Paris, 1786, discarded all these complications, and per-
formed the lateralized operation in the following way. To a certain extent
his lithotome resembled the old one of CoUot. He cut very freely the skin
and cellular subcutaneous tissue ; opened the membranous portion of the
urethra; raised the staff behind the pubis, and at the same time plunging his
bistoury into the bladder ; strongly elevated his right wrist to cut the pro-
state obliquely, and then depressed it to carry backwards the cutting edge of
his instrument, as he brought it out at the external opening, His idea was to
make a large opening into the neck of the bladder, so as thence easily to
extract the stone, a still larger opening in the integuments to avoid infiltra-
tion, or abscess, and to cut but very little of the parts intermediate ; to avoid
the arteries of the perineum which are lodged principally in them, and likewise
to avoid the rectum, so that his wound must have resembled a double triangle
whose narrowest part was in the centre of its length.
ii. ' Procedure of frere Come. — A modification of the lateralized operation for
stone, which actively engaged professonal minds, was that which brother
Come proclaimed himself the inventor in 1748.
This monk contrived an instrument, which being introduced closed into
the bladder through the incision in the urethra, is open by exerting pressure
on the bascule of its outer extremity, and as it is withdrawn cuts the pro-
95
754 NEW ELEMENTS OF
state from within outwards. This instrument since known as the sheathed litho-
tome, at first appeared to oifer numerous advantages. Its handle cut into
facets, numbered 5, 7, 9, 11, 13 and 15 is so arranged that by bringing off the
numbers towards the side of the bascule, one is sure of having a correspond-
ing opening toward the vesical extremity of the instrument. Thus it is
known beforehand, and with great certainty that the neck of the bladder will
be divided to an extent of 7, 9, 11, 13 or 15 lines, according as one or the other
of these dimensions shall have been pitched upon before it is introduced.
Franco speaks of an instrument very much of the same kind, and Bienaise^s
concealed bistoury does not diifer much from it. It was objected to it, that
it was liable to escape from the groove in the staff; to slip between the blad-
der and neighboring parts; to wound the rectum whilst it was being with-
drawn ; to cut the pudic vessels ; and lastly, to pierce the bladder itself,
after it was emptied through the wound in the perineum.
To do away with the latter objection, its point was blunted by Caguet, a
surgeon at Rheims. However, as it finally appears to possess merely the
advantage of cutting the same parts always to a determinate extent, which
are divided by other lithotomes, it has with some show of reason been alter-
nately lauded or condemned. Surgeons but little accustomed to capital ope-
rations, and wlio are not sure of their hand, who are not very perfect in the
anatomical details of the perineum, but who nevertheless venture to cut for
stone, may and even ought to give it a preference.
The lithotome gorget which Bromfield wished to substitute for it, composed
of two pieces movable on one another, is incomparably more defective.
The modifications made on it by Mr. Evans of London, and several operators
in France, which are almost all confined to its bascule and handle, are too
unimportant, too evidently matters merely of taste, for me to stop to discuss
them.
Brother Come performed his operation after the usual method of lateral-
ized cutting as far as the division of the membranous part of the urethra. The
lithotome passed along jpn the nail of the left index finger into the groove of
the staff, was then to be engaged closed in the bladder. Then the surgeon
himself took the staff in his left hand to depress its handle and elevate its
concavity behind the pubis, whilst with his right hand pushed on the point of
the sheathed lithotome in the groove, which thus passed into the bladder, and
the staff, now no longer useful, was withdrawn at once from the urethra.
Having anew assured himself of the existence of the stone, which can be felt
easily with the end of the lithotome, the operator takes hold of the shank of
the instrument with his left forefinger and thumb semiflexed ; opens it by
pressing on its bascule with the right hand ; rests the back of the instrument
firmly against the symphysis pubis, a little to the right side ; directs the cutting
edge of it to the left and backwards ; draws it forth, raising its handle mode-
rately until its blade has cleared the prostate ; slackens the bascule at this
moment ; allows it to reclose by degrees ; and lowers it more and more, and
in such a way, that from the neck of the bladder to the integuments its cut-
ting edge shall as it were have described a half circle, the convexity of which
should be in front, nearly as in the procedure of Moreau.
i. Procedure of Guerin. — Brother Come is far from being the only person
who has proposed a particular instrument for lessening the dangers of litho-
OPERATIVE SURGERY. 755
tomy. A host of others have since his been invented, tne object of some of
which has been to render opening of the urethra more certain ; of others to
divide the prostate neck of the bladder with less hazard. Among the first
are many species of staves; for example that of Guerin, so constructed
that when once placed, its external extremity is sufficiently depressed to be
directed opposite or to face its most convex part, that is to say, the groove of
its urethral portion. It is besides ended by a sort of perforated head, through
which may be carried a long trocar canulated on its inferior surface, and
which passed upon the perineum necessarily falls of itself into the groove of
the staff. We see thence that the incision in the soft parts externally
becomes extremely easy, and that the opening in the urethra off*ers not the
least embarrassment. In all other respects the operator acts as has been
described when speaking of median cutting. An instrument differing from
that of Guerin in having two halves jointed externally by a hinge, has been
employed in England by Mr. Earle, with similar views to those of the
Bordeaux practitioner. Deschamps describes a third also belonging to this
list.
Were the opening into the urethra the really difficult point in the opera-
tion, this species of sound would perfectly answer the end for which it
was designed. But let a surgeon have ever so little skill or knowledge of
parts, it is never at this stage of lithotomy that he stops short. Conse-
quently the instrument of MM. Earle and Guerin will remain merely things
of caprice or individual usefulness, as so many others have done. The com-
mon staff' on which Sir C. Bell has caused the groove to be put on one side,
so as to be able while holding it in the median line, to cut obliquely to the
left when we reach the prostate, seems really only calculated to increase the
difficulties of the operation. As to Mr. Key's staff", which is straight or
scarcely curved for an extent of half an inch towards its beak, it does not
seem to me to deserve any real importance, nor to possess any indisputable
advantage over the rest.
The instruments contrived to facilitate opening the bladder and make it
more sure are of two kinds. Some in fact nowise differ save by feeble
shades of distinction from common bistouries, whilst others are indeed
instruments peculiar in their nature. In this way the lithotome of Cheselden,
a little concave on the back, has been altered in the hands of M. Dubois, into
a little knife with a solid handle scarcely different from the convex bistoury.
In England, M. Blizard employs a long, narrow bfstoury, with a firm handle
like that of the French surgeon, whose point ends towards the back of the blade
by a sort of blunt stylet. Klein, Langenbeck, Kern, Grasfe, in Germany,
have each a lithotome which ranks like the former, in the class of simple
knives or of bistouries of varied forms ; but to whoever will look closely into
them it is evident that all this is entirely optional, and that it is indifferent
whether the one or the other be adopted ; any of which may be replaced
perhaps advantageously by a common bistoury, or probe-pointed one. It is
long since M. Dupuytren, and some English surgeons alike asserted this
fact, that when directed by an able hand, a common straight bistoury is quite
as capable as the most complex lithotome of penetrating the bladder and of cut-
ting the prostate on being withdrawn in a suitable direction. We see also,
by reference to the work of Sabatier, that the surgeon -in -chief at the Hotel
"<^ . N^^V ELEMENTS OF
Dieu has several times operated for stone, by plunging the straight bistoury
bj puncture as far as the groove of the staff, then into the bladder, so as to
divide by its withdrawal the prostate and all the tissues which constitute the
perineum together. This procedure, which reduces lithotomy to the simple
opening of an abscess, is easier than one might imagine. It would appear
that in some cases M. Lisfranc had adopted it; and in teaching surgical ope-
rations to my pupils, I have frequently tried it on the dead body. As how-
ever, it can have no other advantage than that of rendering the operation
more quick of performance by a quarter or half a minute, I do not think
that prudence justifies the establishment of a rule on a like act of dexterity
and skill, so that if a bistoury be used the urethra should be incised as is
usual, and the knife be then slipped along the groove in the staff, as is done
by all other lithotomists.
The special instruments for this purpose of which it remains for me to
speak, are known under the name of gorgets.
j. Procedure of Haivkins. — The first gorgets employed in lithotomy were
simple canals (gouttieres) ending on one side by a stylet or probe point, and
at the other having a sort of handle. They were used to supersede staffs,
and they are so still to facilitate the introduction of forceps in almost every
species of operation. When in this form their edges are round and blunt, so
as not to endanger the parts. It was not before the middle of the last cen-
tury, that an English surgeon named Hawkins conceived the idea of meta-
morphosing the gorget into a lithotome, that is to say, to make it into a cutting
instrument by sharpening one edge near its point.
This instrument, which most English surgeons adopted, is used in the fol-
lowing way. The membranous portion of the urethra being once open, the
surgeon seizes the gorget by its handle, carries the knob at the point into the
groove of the staff, and pushes it into the bladder, being careful not to let go
this latter instrument, which is elevated behind the pubis by a swinging mo-
tion, as the gorget is dividing the left side of the prostate. The apparent
simplicity of Hawkins's gorget, did not however prevent even its admirers
from discovering its defects. Mr. Bell finding that its blunt part was too
broad, had it contracted to prevent it from bruising or tearing parts. De-
sault who did away its concavity, besides adopting Bell's modification, placed
the knob quite straight on the blunt edge. Blicke, fearing that it might stray
out of the groove of the staff, and pass between the rectum and bladder as Sir
Ai Cooper and Mr. S. Cooper state they have themselves often witnessed, so
arranged the knob as that it would not escape before it had reached nearly to
the end of this staff. That of Mr. Abernethy represents as it were, a trian-
gular canal, as is seen also in that of Cline, or else a cylindrical demi-canal
like that of Hawkins. Dorsey has given us an engraving of one, the blade of
which takes off easily, and is of the same width throughout its free extremity
obliquely cut like the kystotome of Desault, and being the only cutting edge.
Lastly, Scarpa who declared himself a patron of the instrument, strove at
great length to prove that a gorget ought to have a very narrow cutting blade
two lines towards its knob, growing larger and larger until it have acquired
a transverse diameter of about seven lines, aad that this cutting edge
ought to be bent at an angle of sixty-nine degrees on the edge which
acts as its back, so that in cutting the prostate it might make a wound,
OPERATIVE SURGERY. 757
the angle of which should also be at an inclination of sixty-nine degrees, as
regards the direction of the urethra. Some English surgeons, apiongst others
Messrs. Dease and Mair, thought that using with it the staff of Le Drangave
more certainty to its use. This proposition was not, nor did it deserve to be
followed. In France, gorgets have found but very few supporters. M. Roux
is almost the only man in Paris who uses them. The least reflection serves
to show the unimportance, I had almost said insignificance, of the variations
in form to which this instrument has been subjected. It is the gorget as a
particular instrument, and not such a form of gorget in particular, which we
are to examine ; and I am surprised that authors of such repute should have
involved themselves in disputes upon this subject. Certain it is, that with a
gorget the rectum or pudic artery will never be wounded, unless some
anomaly exist in the anatomical arrangement ; that the limits of the prostate
either can never be passed ; but as the whole of this advantage arises from
the small extent of wound it makes, it is clear that the same might be obtained
with any lithotome whatever, if a wound of six or seven lines only were to be
made. The inconveniencies about the instrument are, that whatever be the
size of the stone it always makes a passage of the same length ; that it is more
likely than any other instrument to wound the posterior wall of the bladder,
or even to go through the sac, as Mr. Earle says he has seen done, and above
all to divide the tissues by pushing them before it ; in separating the different
layers of the perineum from one another, to relax them in some measure
instead of pressing them downwards from above, stretching them as does the
sheathed lithotome for instance, and almost every cutting instrument em-
ployed by different operators in this second stage so as to dilate and
even bruise as it divides ; of obliging the operator to have several gorgets of
various sizes ; and of never allowing of any incision of more than eight or
nine lines. Perhaps the least disputable advantage which it has, although it
has not been mentioned, is to be found in the direction which it gives to the
incision of the prostate, one of a semilunar shape whose concavity looks back-
wards and to the right, and the arch of which having a cord of about seven
lines in length, ought to stretch two or three lines at least without tearing,
when extended during the extraction of the stone. Under this view Desault's
gorget is evidently the worst constructed of any ; for to attain this end it
ought, augmenting in width on its cutting side, to preserve its primitive canal
shape, or else that of a half canal. Moreover, in this way it would cease to
belong to the performance of the lateral operation, or that properly called
the oblique. The incision would be rather a transverse one, directed
towards the left ischium, whence arises a fresh inconvenience ; that of acting on
a shorter radius of the prostate than that which should be cut in the proce-
dures of brother Come, Cheselden, or Garengeot.
k. Procedure of Thomson, — The deviation from the line first indicated in
lateralized operation is not after all the only one that has been suggested. Dr.
Thomson, in 1808, wishing to avoid cutting the rectum and perineal arteries,
thought of making an incision with a common lithotome, not downwards, but
up and outwardly a little when a backward incision of some lines did not
seem to him sufliicient for extracting the stone. At about the same time M.
Dupuytren, desirous of avoiding the same parts, thought proper to conduct his
incision almost directly upwards ; that is to say, when he reached the bladder
751^ NEW ELEMENTS OF IP(p
he turned the cutting edge of his bistoury, or of Gome's lithotome up a little
to the right, parallel to the ischio-pubic ramus, as if to reach the symphysis.
These modifications were properly abandoned by their inventors on consider-
ing that then the prostate is divided in its least thick direction, that its limits
must invariably be passed, and still further, because the stone has to be ex-
tracted tlirough a point of the inferior strait still narrower than in the oblique
posterior operation.
1. Procedure of M. Boyer, — M. Boyer, who almost always uses the sheathed
lithotome and who is said to be very happy in his operations for stone,
makes his incision in none of the directions which have been pointed out.
Instead of resting the back of his instrument towards the symphysis, he holds
it firmly against the ramus of the pubis and ischium of the right side so as to
be able to direct its cutting edge almost completely across, and to the left
during its withdrawing to divide the prostate from within outwards like every
one else. In doing this the rectum and pudic artery are in no danger any
more than the transverse perineal artery whose direction is almost parallel to
that of the incision, whilst the superficialis perinei is the only one which can
be injured. This is a modification against which no reproach could be urged,
were it not that the prostate has to be divided in the direction of one of the
shortest radii, and that the incision cannot be of more than seven lines in
extent without going beyond the boundary of the gland. The lithotome thus
managed answers all the purposes of the gorget without its objections.
Remarks. — If it be true that the difficulty to be got over in the oblique ope-
ration is to open the prostate as widely as possible, keeping at the same time
within the limits of its outline, evidently the only incision to be adopted is
that which proceeds downwards and outwards. With this supposition the
procedure of Dr. Thomson, and that which M. Dupuytren has tried to bring
into use are unworthy of being discussed. The rule adopted by M. Boyer of
allowing tlie cutting edge of the bistoury to lean a little towards the ischium
is infinitely a better one. For the loss of a breadth of one line in the incision
into the prostate we derive undoubted advantages as regards the arteries and
the rectum. As to the incision made after the manner of Boudou, of Garen-
geot, of Morand, of Le Dran, of Moreau, of Dubois, and of Messrs. John and
Chas. Bell, and of all those who prefer the bistoury with more or less modifi-
cation to particular lithotomcs, and who seek to open the neck of the bladder
extensively, it is a matter of indifference whether the one or the other be fol-
lowed provided that care is always taken to extend sufficiently the opening
into the integuments and other constituent parts of the perineum. Two cir-
cumstances present themselves for consideration in the method proposed by
Lecat ; 1st, the instruments he uses, for which any others may as well be sub-
stituted ; 2d, the idea of only making a small incision into the neck of the
bladder. This is the only distinguishing point in Lecat's operation. De la
Motte had already maintained that there was less danger in dilating, and
even in tearing the entrance into the bladder to a certain extent, than in
incising it ; and we can scarcely be allowed to dispute the justness of the
remark. The error into which its defenders have fallen is that they have not
understood the essential reason for it, and have carried their extension beyond
moderate bounds. In fact, the small incisions of which Lecat speaks are
better than large ones, only as they are confined within the limits of the pro-
OPERATIVE SURGERY. 759
state gland ; and it follows therefore that no other operation for stone will be
more dangerous which does not extend beyond this boundary. I have in
some preceding pages expressed my opinion as to the gorget and its various
forms. The instrument of brother Come remains for my consideration ; and
no one can deny to it the possession of great certainty, great simplicity of
mechanical construction, and the capability of being used by most operators
more easily than the bistoury; only as we shall see by the sequel it may well
be superseded by the probe-pointed bistoury. The principal dangers of
oblique cutting originating in the risk of wounding the rectum, pudic -artery,
and the transverse or superficial arteries, all instruments except the gorget
^re in this respect equally objectionable. If one is careful to examine the
state of the rectum by the introduction of the finger into it, and careful also
not to make the deep wound too large, and the lithotome be handled with a
little dexterity, the rectum will not be perforated. Tlie pubic artery being
always situated along the outline of the pubic arch, is consequently far be-
yond the prostatic limits, and runs in reality no risk of being wounded. The
seat of the superficial artery being in the subcutaneous layer would be so
easily seized, twisted, tied, or cauterized, that opening it could never be a
thing of any importance. The transverse perinei, usually a very small vessel ,
can only be avoided with certainty by making an incision into the urethra,
which shall not begin too near the bulb or too far from the prostate. Hap-
pily the bleeding which follows its division is seldom abundant enough to
become serious. With this view of the case then there can be no danger
in practising the lateralized operation for stone, unless in case of an anoma-
lous distribution of the vessels or of their being of excessive size. A much
more vexatious difficulty is that we cannot obtain by it an aperture of more
than ten or twelve lines at most; too small therefore to admit of the removal
of voluminous calculi.
With a view to obviate this objection of real weight, notwithstanding all
procedures, and all operations, the following method has been set forth.
4. Transverse {bi-lateral or bi-oblique) Cutting for Stone,
A fresh interpretation of the passage in Celsus in latter years has given
origin to a new operation for stone. When speaking of the extraction of
calculi, the Roman author advises that there be made '* juxta anum, cutis plaga
lunata, usque ad cervicem vesicae, cornibus ad coxas spectantibus paululum ;"
then, that at the bottom of the first wound the instrument be carried in to
make another which should be transverse, and open the cervix-vesicae by
going down to the stone. Now it is this passage, until lately so construed
as to have given rise to lateral cutting, lateralized cutting, and the apparatus-
minor, formerly described by the Greeks and Arabians, which interpreted
truly constitutes the principle of this new procedure.
The words plaga lunata, and plaga transversa, had, it is true, more than
once puzzled commentators on Celsus ; but by substituting the singular for
the plural, and translating ad coxas, by * towards the thigh,' th^y fancied that
they had got over the difficulty. In vain did Davier, in the year 1734, April
15th, sustain at Cochu, before the faculty of Paris, that in Celsus's apparatus
a crescentic incision is made in the skin near the anus, the ends of which
760 NEW ELEMENTS OF
crescent turn towards the thighs ; in vain did Heister cause lisman to repeat
the same thing in November, 1744 ; in vain did Normand de Dole complain
of the slovenly way in which the works of the ancients were perused, and
recalled the fact to mind that in the Celsian operation the crescentic-shaped
incision ought to be situated near the anus with its horns turned rather to-
wards the thighs of the patient ; in vain the same interpretation was again
urged by Macquert in a thesis defended in April, 1754 ; by M. Portal in his
Precis de Chirurgie, published in 1768, and by Deschamps himself in his
Treatise on Lithotomy ; no one gave himself the trouble to turn it to any
account. A second ambiguity which Bromfield vainly endeavored to clear
up and remove, was to know whether the words cornibus spectantibus paulu-
lum ad coxas were to be construed to mean a semilunar wound whose ends
were to be turned forwards rather than backwards. Every author whom I
have cited has, it will be seen, adopted the first version. Bromfield alone
inclined to the second, which in truth seems to be the correct one ; for coxas
among the ancients was generally applied to the large bones of the pelvis,
and the ischium in particular. Be this as it may, the question has been con-
sidered under its proper light only since the beginning of the present cen-
tury. In the year 1805 M. Morland of Dijon mentioned in a thesis some
attempts made by M. Chaussier on this subject, whence it resulted that a
semilunar incision with its concavity looking backwards allows of an easy
entrance into the bladder and of extraction of a stone. Again this was a
lost labor, and Chaussier himself had forgotten his own investigations, when
they were reproduced in 1813 by Beclard, almost in M. Morland's words,
and with as little success. The convincing and forcible reasons urged by M.
Turck in 1818, at Strasburg, in favor of the same principles, again failed to
awaken the spirit of inquiry
But, in 1824, M. Dupuytren engaged in an attempt to render lithotomy
less dangerous, entertaining the same ideas as MM. Chaussier, Beclard, and
Turck, immediately almost put them in practice on a living subject, and was
speedily convinced that there existed in it an inestimable way of operating
for stone. Beclard, not quite so sanguine, but who had never forgot-
ten the subject, and who even, according to M. Olivier of Angers, had himself
some few times performed it, recapitulated anew its advantages to the Aca-
demy, whilst M. Dupuytren at the Hotel Dieu was making its importance
be fully felt. Since that period numbers of surgeons have adopted it, and it
is now considered as one of the best methods, if even it may not be regarded
as absolutely the very best of all.
a. Procedure of Chaussier. — It is shown by the essay of M. Morland,
that Chaussier, in conjunction with M. Ribes, began by incising all the soft
parts between the anus and the bulb of the urethra with the point of a scalpel ;
that he had entertained thoughts of having a double grooved staff, one groove
on the right side and one on the left, so as to be able to divide the mem-
branous and prostatic portion of the urethra only on one side, or successively
on both, if it seemed to be rendered necessary by the size of the stone; tliat
in his opinion the staff might be superseded by the grooved staff as advised by
Le Dran, because in carrying it by the wound it was easy to cut upon it to the
left and then to the right; that he had thought besides of a sheathed lithotome
with two blades, and of the sheathed scalpel of Louis; but that he was
OPERATIVE SURGERY. 761
also cautious to observe that in such a case, the best of all was intelligence,
guided by exact knowledge of situation and nature of parts.
b. Procedure of Beclard. — The instrument selected by Beclard was a spe-
cies of rather wide gorget, scarcely concave, cutting on both sides, and ending
in a little tongue in its convex direction. He mentions likewise the double
litliotome, leaving every one at liberty to adopt or dispense with it at pleasure.
He had also constructed a knife whose blade was shaped like a leaf of sage,
very like Cheselden's lithotome and for the same object. He divided the
skin and other tissues in the way pursued by Chaussier.
c. Procedure of M, Dupuytren. — The attempts of Chaussier and Beclard
remaining unheeded, it is to M. Dupuytren, in fact, that transverse lithotomy
owes all its importance. In its performance this surgeon employs two parti-
cular instruments, the one is a bistoury with a solid handle, a kind of scalpel
cutting on both edges for an extent of some lines near its point ; the other is
a double lithotome, the idea of which must have been suggested by an expres-
sion of Franco's, and which is a very exact representation of the incisory
forceps of Tagault, delineated in page 366 of Joubert's addenda to Guy's
work, printed in 1649, which had been mentioned by Fleurant in speaking
of operations on the female, and of which Beclard and Chaussier had equally
thought, but which it was reserved for M. Dupuytren to render as simple as
possible and to bring into general use.
According to Sabatier, its sheath is concave on one of its surfaces, instead
of its edge, as in Come's instrument. Its two blades are also concave, so that
they may, by their separation, represent a curve, and so avoid the extremity
of the rectum. Its handle is conical, instead of being simply square, and by
means of a screw may be made to approach or separate for as many lines as
are wished from the union of the sheath with the blades, and give to the whole
a determinate degree of width of opening. M. Amussat thinking this too
complicated still, has proposed to substitute for it a kind of scissors which cut
on their edges when they are opened, and which are a blunt instrument when
closed ; but these scissors do not fulfill every purpose proposed by the use of
the double lithotome. In fact, a simple transverse incision is not what the
surgeon seeks to effect ; it must also be oblique backwards and outwards on
either side, so as at once to include the two largest radii of the prostate. M.
Dupuytren, who early discovered this fact, found all that could be asked for
in this particular in the modifications effected in his original instrument by
Dr. La Serre, and that ingenious cutler M. Charriere particularly. From
the description given in the essay of M. Bouille, the instrument of M. Char-
riere is, I find, so constructed that pressure on its only bascule which is
situated on the handle, causes the two blades to leave their sheath imme-
diately, and describe by their separation a curved line exactly similar to the
outer incision, so that they divide the prostate obliquely backwards towards
the ischial ^de, encircling the exteiior surface of the rectum to the right and
to the left. Lastly, instead of the usual staff, M. Dupuytren has contrived
one which is swelled at the seat of its greatest convexity, the better to distend
the urethra, and whose groove is more shallow towards the point than the
centre. The patient is to be placed as if for any other species of operation
for stone. The surgeon seated in front of the perineum, makes tense the in-
teguments with his left han4. With his right hand, holding the scalpel, he
96
762 NEW ELEMENTS OR
makes a semilunar incision ; commences it near the right ischium ; passes six
lines in front of the anus, and ends it within the left ischium, so tliat its horns
may fall towards tlie centre of the space whicli separates the anus right and
left from the tuberosities of the ischia. Thus he successively divides the
several layers which occur, pressing most strongly on the median line until
he reaches the membranous portion of the urethra, which he cuts longitudi-
nally, lays aside the scalpel, takes the litliotome, whose handle has previously
been set at a proper degree of separation, rests its point upon the staff, its
concavity looking upwards, and pushes it on into the bladder, as is done when
brother Gome's instrument is used. Before it is opened, it is made to
describe a half circle, in order that its concavity from looking upwards may
become lowermost and look towards the rectum. Then it is opened and
withdrawn in the direction of the external wound, the operator having seized
it with his left thumb and forefinger a little beyond the handle, whilst with
his right he keeps it steadily open to divide the prostate from within outwards
as well as the soft parts which the scalpel had not encountered. Undoubtedly
the scalpel may perfectly well be substituted for the common bistour}^ in this
operation ; the lithotome of frere Come, drawn from left to right, will cut the
same parts; the double cutting edged gorget used by Dr.Physick as early as
1804, which Sir A. Cooper sometimes employs, and which was proposed by
Beciard, is very proper too for effecting this double incision. In fact, the mere
probe-pointed straight ordinary bistoury even, may be used instead of any one
of these instruments for the division of the prostate. But it is impossible to
refuse to the double lithotome, the immense advantages of completing the
operation at a single stroke ; of stretching the parts more certainly whilst it
divides them ; of making a wound of greater regularity ; and above all of
giving it a true curve, and not merely making a V shaped incision, which is all
that can be reasonably expected from the use of a bistoury or any other litho-
tome. Gorgets have the same disadvantages here as every where else : that
of a tendency to detach parts and crowd them back towards the bladder
tluring the incision, which thereby becomes uneven and unequal in dimen-
sion. Reasoning at once detects the value of this procedure. If each blade
of the lithotome is separated only four lines, a wound is inflicted evident at
least eight lines long ; ten lines long if the calibre of the urethra be included.
Now, as every oblique posterior radius of the prostate is nearly ten lines in
diameter, it is clear that an extent of tw^enty lines is thus afforded to the
wound. Again, if the incision is a true curve, any traction made on it to
straighten it will lengthen it still more ; the posterior portion of the prostate
pressed back along with the rectum whilst we are seeking to draw forth the
stone, easily becomes a second curve parallel to the first, to such a degree
that a calculus twenty to twenty -four lines in thickness, and five or six inches
in circumference, might strictly speaking pass through this aperture and tear
nothing in its passage.
In this respect, no species of perineal cutting for the stone, can at all com-
pare with the transverse method. It threatens the intestine only when it
is enormously distended on either side of the bas-fond of the bladder, because
it cut the tissues outwardly and a little backwards; and even then only
when it is necessary to give the lithotome a very considerable width of open-
ing. The pudic artery is equally sheltered from injury ; so also is the super-
i
OPERATIVE bURGEHY. 763
ficial artery whenever it occupies its normal situation. The transverse artery
can be but seldom reached, for the most advanced point of the incision must
be situated behind the bulb of the urethra, in which it is seen principally to
distribute itself. The only branches which could be divided are the posterior
twigs of this latter vessel, when they are unusually large about the anus, and
also the anterior divisions of the hemorrhoidal. The first incision falling
upon the membranous portion of the urethra, and the two blades of the instru-
ment being obliged first to extend themselves outwardly, the verumontanum
and ejaculatory ducts are necessarily out of the reach of danger.
Nevertheless, it must not be forgotten, that in some persons the lower dila*
tation of the rectum is continued on as far as beneath the prostate ; hence, if
the cut be made too near the anus, we might easily pierce this gut in the first
stage of the operation, as is said once to have happened. A danger which
reasoning might have suggested is that of urinary fistula. It would at first
sight appear that a wound so extensive in the posterior and inferior wall of
the urethra would be but little disposed to adhesion, immediate or secondary.
Experience, the only judge competent to decide upon such subjects has not
confirmed the fears thus entertained. Its tenor has, on the contrary, been to
show that as a general rule the urine assumes its natural course sooner after
the bilateral procedure, than after any other. It would appear also that this
method of operation has the advantage of being seldom followed by infiltra-
tion or suppuration in the thickness of the perineum ; which may be explained
by the remark, that the incision on either side extends beyond the pelvic apo-
neurosis; that it cuts but very little either of the origins of the superficial or
horizontal aponeurosis ; and that it is confined to the division of the internal
layer of the ischio-rectal aponeurosis.
Thus far, twenty-six cases operated on by this method, are counted at the
Hotel Dieu, and not one has died ; and of a total of seventy mentioned by M.
Dupuytren six only have perished. If even, as regards accidents it be no
better than any other method, it must at least be admitted to be quite as good.
To derive from it every possible advantage, it appears to me that the incision
ought to fall upon the base of the uretro-anal triangle, so as to spare both the
bulb and the anus; then to come down upon the posterior part of the mem-
branous portion of the urethra, a little in advance of the prostate, having cut
through integuments — 'Subcutaneous layer — the intercrossing fibres of the
sphincter ani, of the bulbo cavernosus, and transversus perinei muscles, and
of the aponeuroses to the point at which they are lost in one another. The
horns of the incision also should be so far extended in the direction of the
ischio-rectal excavations, as to oppose no obstacle to the escape of fluids out-
wardly. If bilateral cutting did not allow of as rapid a cicatrization of the
wound, as the incision on one side only of the prostate, the operation should
then certainly, as Beclard thought, and as Scarpa proposes in his letter to
M. Olivier, be a reserved method, useful only in cases where the stone is of
great bulk ; but since this is not at all the case, and the contrary happens, I
see nothing to prevent it from becoming a method of general adoption.
Procedure of 31. Senn. — M. Senn, a surgeon of Geneva, who studied for a
long while in the Parisian hospitals, endeavored to prove, in his thesis, that
instead of operating with a double lij^hotome it is better at first only
.10 divide one of the oblique radii of the prostate, and that if then the stone
764 NEW ELEMENTS OF
be too large the gland should again be cut transversely to the right at a
second stroke with a straight probe-pointed bistoury. Proceeding upon
geometrical data, he asserts that the triangular portion, thus cut at the expense
of the urethra and its surrounding gland, which has its base backwards and
to tiie right side, creates when distented or pushed towards the rectum in
extracting the calculus, a larger orifice than the procedure of M. Dupuytren
aiFords. M. Senn's method is different from Dr. Thompson's, advised by him
in cases of large stones, in that one of the incisions is to the left, and another
to the right ; whereas in that of the English surgeon, one was made up and the
other down on the same side. To me it is objectionable as being longer, and
not altogether as certain as cutting by the double sheathed lithotome, and pos-
sessing no real advantage over the latter. It had been established as a prin-
ciple by M. Martineau of Norwich, and it had also been advised by Louis himself,
always to introduce the finger into the wound, when any difficulty in with-
drawing the stone is experienced, with a view to detect the seat of resistance,
and to enlarge the incision with a bistoury, either backwards, upwards, or
outwardly, as Saucerotte did so successfully ; whence it follows, that by some
one or other procedure of the lateralized cutting, of oblique or transversal
cutting modified by Louis, MM. Martineau, Boyer, Thomson, Dupuytren,
and Senn, every radius of the prostate gland has been divided. From this
circumstance arose a new method of performing lithotomy.
5. Quadrilateral Cutting. — In the year 1825, M. Vidal Cassis, who says
that he had been engaged in researches in the hospital at Marseilles, feeling
the necessity of not exceeding the limits of the prostate in enlarging the
entrance of the urethra, and still the want of as large an opening as possible,
was induced to propose in a thesis to incise this organ in its four principal
radii, viz. backwards and to the left — backwards and to the right — and ob-
liquely forward on two sides. This quadruple incision could be made,
according to M. Vidal, at one stroke of a four blade lithotome, yet he prefers
using a simple bistoury, carried successively in the four directions. The
reason of this difference is, that if it be a small calculus only, it is optional
with the surgeon to cut it only by one, or two, or three sides. His method has
been pursued at the Hospital at Aix, by M. Goyrand, who speaks very
favorably of his trials of it. I have myself had occasion to practice it upon
a patient in whom there was a stone of two inches and a quarter in its largest
diameter. The man was sixty nine years of age, and worn out with long
continued suffering. I operated in the manner of frere Come; and it was
not until I ascertained the impossibility of extracting the calculus without
lacerating the parts, that I had recourse to that of M. Vidal, modifying it
however in this way ; that I might not be obliged to let go the stone, an
assistant took charge of the forceps which held it, and raised them up a little
on the left side. With a straight bistoury, carried in on my forefinger, I was
aWe to incise the right posterior radius of the prostate, and then did the same
to its transverse radius a little above. The operation completely succeeded,
and the health of my patient was afterwards perfectly re-established. Pur-
suing this idea, each incision may extend only two or three lines, and yet
together give an opening gained of nearly one inch. If they be made to extend
to four or five lines, we see at once that an orifice of fifteen or twenty lines
results ; and thus a passage may be made for the largest calculi, without in-
OPERATIVE SURGERY. 765
curring the slightest risk of transgressing beyond the prostatic bounds or of
wounding the rectum, or any of the arteries of the perineum. If bilateral
cutting prove insufficient, or any fears are entertained about doing it, the idea
of M. Vidal offers us then a resource vi^hich ought not to be despised. Sup-
posing it to be at once decided on to operate by it, there would, in my opinion,
be found an advantage in using the four bladed lithotome constructed by M.
Colombat, rather than in making; successively four incisions with a bis-
toury of the common kind, for the very same reasons which make the double
lithotome preferable, in the simple bitransversal cutting. Besides which,
it is necessary to recollect that M. Vidal incises the prostate in the direction
of its oblique radii, and not from before backwards or transversely, as is
erroneously stated by the recent editors of the works of Sabatier.
§ 3. Recapitulation of tlie Method of Operation in different Species of Perineal
Cutting.
77ie Apparatus. — The surgeon before he begins the operation, is to arrange
such instruments, &c. as may be necessary during its progress, according
to the procedure on which he has determined. These thing are, 1st,
staffs, sounds, and catheters of silver or gumelastic, in case of need ; 2d, a
common straight, a convex, and a curved Pott's bistoury, a straight probe-
pointed bistoury, one or more cutting gorgets, and if it be intended to make
use of it, one of the lithotome knives, previously mentioned ; 3d, brother
Gome's sheathed lithotome opened for children to No. 5 or No. 7, to No. 9 or 1 1,
seldom to 13 or 15, for adults; 4th, the probe-pointed scoop (tige a curette),
having a crista on its plane surface ; 5th, a simple gorget ; 6th, straight and
curved forceps, of various sizes; 7th, long polypus, dissecting and dressing
forceps, straight and curved scissors ; 8th, a needle fitted to a handle, either
that of Petit or of Deschamps, and some common armed suture needles;
9th, a plain canula of silver or of gumelastic, another fitted with a sheath
(chemise). Pledgets of lint fastened in their centres by loops of strong and
well waxed thread; 10th, fresh lint, balls of it, bandages, compresses, lacs
or lithotomy fillets, water, sponges, some styptic liquor, a strong syringe, and
lastly, several wax candles, if the natural light be apparently not powerful
enough for all purposes.
Of the Staff. — Amid all these objects, one or two, for example the staff and
the forceps, require a particular choice to be exercised in their selection.
Cxteris paribus^ it is better to have the staff very large than too small. The
larger it is the better it distends the urethra, the more easily is it felt at the
bottom of the perineum, the better it conducts other instruments, and it
renders the patient less liable to be wounded. The groove is to be at once
wide and deep, otherwise it would be difficult for the finger to detect it
through the thickness of the urethra, nor would the lithotome receive a suit-
able direction. After this, it matters but little whether it be semilunar in its
transverse section as they used to be made, triangular as advised by English
surgeons generally, or square as M. Dupuytren recommends. The cul-de-
sac in which it ends being at best of but doubtful utility, and perhaps liable
to impede the motion of the point of the lithotome, had better taper off in-
sensibly, to preserve the rounded and blunt form of the staff. If the groove
766 NEW ELEMENTS OF
were to be extended as far as to the point of the staff, it would be advantageous
only when the staff was held stationary and not raised up towards the pubis
before the division of the prostate, because then the point of the bistoury used
is more firmly kept in it. The curve of this instrument need neither be
carried all the way to its point ; but this point, unless we wish to see it retreat into
tlie urethra, when we suppose it still in the bladder, must extend at least an
inch or two beyond the axis of the handle. It is scarcely necessary to add,
tliat the shape of the flat piece on the handle is a matter of taste entirely, and
that it is rendered in nowise more convenient by substituting rings after the
manner of Ponteau's, nor by attaching a wooden handle to the stem, as in that
of Lecat.
Of the Forceps. — The forceps in ancient use, which were jointed like scis-
sors very near the grasp, had a double inconvenience, that of opening wider
in the wound than in the bladder, and of seizing the stone badly. The mere
removal of the rings upon the outer sides of the handle did not suffice to
remedy this defect, to effect which the handles were so arranged as to cross
one another more or less within, and thus before they extend beyond the axis
of the instrument without, they allow of the forceps opening considerably.
That variety which has the two blades parallel when separated, and not
divergent, and which has a lateral articulation, such as is to be obtained at Mi
Charriere's, has an additional advantage of letting go its hold less easily, and
of better adapting itself to the form of the stone.
Position of the Patient and the Assistants. — A common bed is too large, too
yielding, and generally too low, to be substituted in private practice for the
operating table which is used in public institutions. However, I myself, am
not fond of those mechanical contrivances which some are in the habit of
having conveyed to their patient's houses. Therefore, M. Heurteloup's table,
and that of MM. Tanchou, Rigal, and others, however ingenious they may be,
seem to me to be no more indispensable than M. Rouget's bed, or the litho-
tomy table of the ancients. A commode, a common table, or a cot, firmly
fixed and properly covered, are much less alarming, and always quite sufr
ficient for a surgeon who has no desire to acquire notoriety by the use of any
particular means. What is wanted, is that the patient should lie on his
back, have his head and chest flexed, or moderately raised, so as that his pelvis
be not sunk in the mattress ; that the perineum pass beyond its edge ; and
that the assistants may move easily around him. At the present day, the
Celsian method of seating the patient doubled up on the knees of two strong
persons, and then of binding him with ligatures passed under the armpits,
roots of the tliighs, over the hands and i^^U as prescribed by mnemonists, is
no longer thought of.
The list bandages, in a figure of 8 form, employed by Ije Dran, are
not necessary. When it is remembered that no species of confinement
has ever been advised in operations for hernia or aneurysm, we see no reason
why in stone there can be urgent need of any unless iht patients are
children or lunatics. I have so far dispensed with it, without ever having
reason to repent doing so; although in a patient under my care at La Pitie,
from whom in October, 1830; I removed an immense stone, the operation was as
laborious a one as possible. If, nevertheless, prudence or necessity induce one
to prefer it, we requiie a flannel bandage, or failing in this, a strip of flexible
OPERATIVE SURGERY. 767
linen of three fingers' breadth and two or three yards long. With this band-
age, doubled where the loiip is, we make a running knot, which is carried
over and tightened on the patient's wrist, who then takes his heel into his
hand, leaving the thumb on the fibular side, the fingers below, and the radial
edge of the hand forwards. The two ends of the bandage are then taken by
the surgeon, who separates tliem, carries one inwards, the other outwards,
crosses them over the ancle, carries them to the sole of the foot, brings them
up, then backwards, and then lastly forwards, where he fastens them in a
bow, being careful to leave the free extremity outwards. The foot and hand
of each side thus confined are confided to two assistants, who stand on either
hand, on the outer side of the limb, their backs turned a little towards the
head of the bed, performing the same office exactly as if no ligatures were
used. Whilst with the hand which is towards the pelvis each assistant
seizes the corresponding knee to bring it from the axis of the body, he em-
ploys the other in grasping the foot by its inner edge and back, pronating it
outwards ; if he were to lay hold of it below, the patient might use this hand
as a fulcrum to elevate his pelvis, which is particularly to be guarded against.
This disposition to raise the pelvis, which is particularly noticed among chil-
dren, joined to a rotatory motion from right to left, is so difficult of control,
as to require the co-operation of a third assistant, who should be tall and
strong if possible, and who is to stand on the left side. By the application
of the palms of his hands on each crista of the ilia, with the thumb of each
hand spread over in front from the anterior superior spinous process into the
fold of the groin, he manages every movement by slight efforts of pressure,
and in general with but little fatigue. A fourth assistant seated on the table
or the bed watches over the action of the head, and closes the patient's eyes
with a compress. A fifth stands to the right, opposite the side, to raise up the
scrotum and support the stall*. Lastly, a sixth is at hand to pass to the sur-
geon such instruments as he requires in the course of the operation.
Introduction, and Location of the Staff. — Before proceeding to the division
of parts, the operator introduces the staff into the bladder, and does not
permanently locate it until he has himself again recognized the presence of
the st(fne, and pointed out its existence to some one or other of liis assistants.
It has long been an established rule to let the flat handle lean towards the
right groin, so that its convexity shall bulge out the perineum more or less
to the left of the median line, and obliquely backwards towards the ischium ;
but it is doubtful how far this rule is a good one, or any other force than that
of long established routine, particularly when we mean to open the prostate
with a gorget or the sheathed Uthotome In fact, the inclination given the staff
does not change the direction of th« parietes of the urethra, as respects the
axis of the canal. What matters it after all that the urethra be opened on the
side or upon the median line, when we have only to do with its membranous
portion, or to make a way for the entrance of other instruments? The only
good reason which can be given for this practice is, that perhaps it affords greater
facility for avoiding the bulb, by the crowding back to the left of that portion
of the urethra which conceals this enlargement, and which consequently be-r
comes no obstacle in the remainder of the operation. It is, therefore, nearly
optional to place the catheter to the left, as is generally done, or on the median
line, as is preferred by MM. Scarpa and Astley Cooper, even in performing
7G8 NEW ELEMENTS OF
the lateralized operation. Instead of holding it ourselves with the left hand
with a view to direct its movement better, and alter its position according to
circumstances as many do, following the advice of Ponteau, it is usual among
surgeons at the present day to entrust the statF when its situation is decided
on to an intelligent assistant, who ought to be well acquainted with its
mechanism and uses.
First Stage.' — The surgeon standing up, or if the relative proportions of his
height with that of the patient seem to require it with his right knee on the
ground, or upon a stool if necessary to support it, armed with the bistoury he
has selected in his right hand, first cuts through the integuments, which he
makes tense with the thumb and fingers of the other hand, not heeding the
scrotum which is gently upheld by the assistant who holds the staff with the
right hand. This incision begins on the left side of the raphe about an inch
in advance of the anus, is to stretch obliquely backward, and end midway in
the space which separates the tuberosity of the ischium from the opening of
the rectum, its length being about four inches. Made nearer the scrotum \%
exposes to infiltration, and no object is gained. It is useless to prolong i^
towards the sacro-sciatic ligament. Were it any shorter it might interfere
with the extraction of the stone, and would not favor sufficiently the escape
of urine. Nearer to the median line it would frequently fall upon the
rectum; and if it were practised as Roux did, very near the ischio-pubic
ramus, it would not preserve its parallelism with that in the deeper seated parts.
The bistoury again applied to its upper angle, divides the subcutane-
ous layer, the posterior edge of the transverse muscle, and successively all the
other layers which intervene between the skin and urethra, carefully bearing
most firmly on the centre part, and not on the two ends of the solution of
continuity.
Rather than to continue this manipulation until the instrument is bare in
the urethra, it is better to feel through the yet undivided tissues for the grove
in it with the fore finger, and place the right edge of the fissure between the
nail and pulp of the finger, the radial edge of which is looking downwards,
The surgeon sliding the point of the bistoury which he has not laid aside,
like a pen upon the nail which is kept motionless, pierces the lower wall of
the urethra, a little in advance of the summit of the prostate, and strikes upon
the fissure in the staff. The forefinger which guides it is then raised on the
back of the bistoury, pushes its point towards the gland for an extent of three
or four lines, whilst the operator with his other hand raises the handle and
continues to press it against the groove in which it is engaged. Should it slip
out, the rectum runs the risk of being pierced. Uretro-cutaneous fistula
originate from this cause, of which MM. Dupuytren and Begin, cite an
instance, and of which I know myself another. The forefinger now resumes
its steady position at the edge of the staff, and then the right hand draws out
the knife, whilst at the same time it depresses its shoulder so as to divide yet
more largely the layers nearest the urethra.
Second Stage. — The period for introducing the lithotorae, which ever it may
be, lias now arrived. If it be that of brother Come, the operator takes hold
of its handle, not touching its bascule, strikes its beak over his nail into the
opening in the urethra, so as to strike perpendicularly on the groove in the
staff, moves it along it upwards and downwards to be sure of its having en-
OPERATIVE SURGERY. 7*69
tered, and when he perceives the contact of the two metallic bodies, he rises,
if he has been kneeling, takes his fore-finger out of the wound, takes the staft'
into his own hands, lowers its flat handle and tilts up the point with his left
hand, whilst with his right he slides the summit of the lithotome along the
groove into tlie bladder, a gush of urine from which immediately denotes its
having entered.
The same precautions are called for by the use of a gorget; nor does
prudence require less when a tongued or probe-pointed bistoury is used :
small solid handled knives, straight or convex are employed. If the
visceral end of the staft' were not tilted towards the symphysis pubis to make
way for these instruments, they would equally cut the prostate it is true;
but then, either their point or their edge will almost inevitably strike tlie
trigonal vesical space so as frequently to penetrate it from side to side. By
following its groove, on the contrary, owing to this elevating movement, they
bring it into correspondence with the vertical axis of the bladder, and pene-
trate with impunity as deep as may be required, so that on withdrawing them
we may give the incision all necessary extension.
The staff having performed its office is now withdrawn. The hand in
which the handle of the lithotome is held, slips some fingers below its bascule
and opens it; the other hand takes hold of its back on the level of the articu-
lation of the sheath with its blade, the thumb on the right side, the forefingei-
semiflexed on the left side, its radial edge being directed towards the pubis.
Its cutting edge looking in the direction of the outer incision, or in any
other way if it be preferred, both hands are to unite their efforts to withdraw
it. It is the part of the right hand to prevent the sheath from leaving, as it ik
being withdrawn, that point on the arch of the pubis against which its dorsal
or concave edge had at first been applied.
The right hand, which has to draw it forth, has two dangers to avoid. By
raising the wrist too high the incision at its base would be deeper than at the
point of the prostate; too considerable a depression of it would not only-
produce the contrary result^ but expose the rectum to the danger of being
wounded. If it were not kept firmly pressed against the pubic arch there
would be no fixed point, and the dimensions of the wound would vary
according as the blade should be brought down with greater or less force :
one of the inconveniences attending the gorget and the bistoury.
Whatever be the instrument with which this separation of parts is made,
we should find that by saving the tissues situated immediately below the
prostate, as advised by Morand, no other advantage would be gained than
more. certainly avoiding the rectum, for it is not here that the transverse
artery of the perineum is situated ; but a dangerous obstacle would result
to the passage of the urine.
As on the other hand the intestine is sufficiently well protected by the
obliquity of the incision, it is unnecessary to follow this advice. The
more the axis of the wound approaches the perpendicular, i. e. the axis of the
body, the greater is the chance that neither abscess nor infiltration will occur.
On the whole, the deep incision being intended to enlarge the entrance of the
urethra as much as possible without going beyond the limits of the prostate,
ought to bear upon the greatest radius of this gland, not only from the centre
to the circumference but also from before backward, and so that the circle
97
770 NEW ELEMENTS OF
of its base only be respected. This is a problem to be solved in the lateral-
ized operation. Now, the smallest reflection shows us that to do this there can
be no advantage in cutting the membranous portion of the urethra ; and that
it is alone necessary to open this duct near to the summit of the prostate, and
consequently back of the horizontal aponeurosis of the perineum. For the
same reason, it wUl appear how perfectly useless it is to continue the incision
of the other tissues in front towards the pubis, because its only object is to
make a passage sufficiently large for the stone ; and that for the sequelae of the
operation, the escape of urine, it is particularly necessary that its enlargement
should be made in a backward direction.
Third Stage. — The lithotome having now become uselp-^s, is now passed
to the assistant, and its place instantly taken by the left forefinger, which
being introduced from below upwards, and from before backwards, serves to
ascertain, 1st, the internal condition of the organ ; 2d, the position, sometimes
the size, the form, and even the number of stone's which it contains ; Sd, the
dimensions of the wound. Care must be taken that the finger in its passage
does not detach either the intestine nor prostate, by getting by mistake
between these parts. Before it is withdrawn the probe-pointed bistoury is
conducted in upon it to enlarge the wound if too narrow, either prostatic
or perineal, in one direction or in the other; after which it serves to conduct
the probe-pointed scoop, the gorget, or else the forceps. To do this, it had
better be placed with the nail turned backwards in the inferior than in the
superior angle of the wound ; for the reason that the instruments it is to direct,
have a greater liability of escaping backwards between the tissues than they
have forwards. The scoop being longer and thinner than the gorget, pervades
the vesical cavity better, and reaches the stone more easily wherever it be
situated ; but is afterwards rather less convenient as a guide to the forceps.
In a great majority of cases, however, both may be dispensed with ; and the
forceps be passed in immediately upon the finger. As soon as their duty as
exploring agents is finished, they are brought back instead of the finger; so
as to be able to depress the posterior angle of the wound with whichever one
we employ. With the right hand now at liberty, the operator presents the
forceps above, one grasp or blade to the left and one to the right, and slipping
them in on the gorget,-- or embracing the crista of the scoop between their
half opQn edges, pushes them as he had done for the finger, penetrates into
the bladder in this way, and at the same instant disengages the conducting in-
strument. Before we think of seizing the calculus, we try again to touch it
by various motions of the instrument. All this makes the latter stage of the
operation sometimes the longest of any and the most difficult, though it is gen-
erally the simplest and speediest. The surgeon then opens the forceps with
both hands ; the forefinger and thumb of each acting on the corresponding
ring. When the blades are far enough apart, he turns it suddenly round
on its axis, so that it describes the quarter of a circle from right to left;
so that one spoon becomes quickly the lower, the other the upper; the lower
one raking in a measure the wall of the bladder, and slipping beneath the
stone. If this movement does not succeed the first time, it is repeated,
* This gorg'et, called « simple," is not a cutting- instrument, but merely a grooved body
attached to a liandle, of varying- size. Its use is to conduct the forceps to the stone, and
ivence is called ** gorgeret conducteur.*'
OPERATIVE STTRGERY. 771
eitlier in the same way or from left to right, or by elevating or depressing
the wrist a little more. The stone when grasped, may separate the handles
of the forceps more widely than it was at first supposed it would; this is
owing to its being too near the joint, to its not being seized in its smallest
diameter, or to an erroneous idea of its size. In the two former cases this is
remedied by pushing forward the calculus with the scoop, or by moving it
about until it presents by its thinnest part without letting go of it entirely.
In the latter case there is no other resource than to cut away the frenum,
if the prostatic opening does not appear large enough. It is better to let it
go and seize it again, than to persevere in attempting to rectify its malposi-
tion in the grasp of the blades which hold it; understanding that if it be not a
very large one all these precautions will be found unneeded. If the stone
should be a flat one, and much longer in one direction than in the other,
although seized by its smallest diameter, it might need relaxing, and then to
be' seized again if it came crosswise to the wound. The same thin"; will also
happen if it be somewhat elongated, cylindrical, or shaped like a girkin.
Tbese peculiarities are pointed out to exist, by the insurmountable resistance
which is all of a sudden offered at the moment that the forceps seems entirely
to be leaving the bladder.
The forceps, even though they have never been opened, having an interval
between their blades that they may not pinch the inner membrane of the
organ, may have received the stone if a small fiat one between them, and
may contain it in one of their spoons unknown to the operator. This may
be suspected, if having touched or endeavored to lay hold of it we no longer
feel it any more. The forceps is in this case to be withdrawn to examine as
to the fact. Besides, it is not very uncommon to see small stones escape with
the stream of urine, or stop for a while in the trajet of the wound, so that
their existence is rendered doubtful.
Let us suppose now that the stone is fairly seized. The forceps being
again placed horizontally, the surgeon takes hold of the rings on the handle
with his right hand, fastens them with his left hand turned supine, as near the
grasp as possible ; the fingers being below, the thumb above. He then begins
his traction, after being well satisfied that the stone is free, and the only thing
grasped by the forceps. To do this he presses it down with the thumb of one
hand, that it may press principally against the posterior angle of the wound,
whilst the other hand performs the necessary tractive efforts. These are
made?' from right to left above downwards, rather than directly forwards,
being careful to make them follow the direction of the axis of the pelvis as
in extracting the head of a foetus.
Should the straight forceps pass constantly over the stone so as not to be
able to enclose it in its spoons ; in a word, if the stone escapes, owing to its
having swerved from its position, being too low or situated in too deep an
excavation, curved forceps are indicated. They are introduced like the
others, and their cavity is turned towards the direction of the stone to .seize
it; they are drawn out in a contrary one for its extraction. That species of
forceps resembling the obstetrical instrument invented by F. Come, are
indispensable only for very large stones which are accurately encircled by
the bladder. The branches are introduced separately, sliding them between
772 NEW ELEMENTS OF
the parietes of the organ and the foreign body ; they are then locked, abso-
lutely as in manipulating with midwifery forceps.
The calculus being brought out, it is not to be laid aside until its appearance
has been inspected. If it is rounded, of an elliptical, oval, elongated, but
destitute of angles and facets, we are entitled to believe that no others exist
in the bladder. Calculi covered with projecting roughnesses induce the like
belief. Those which present us with surfaces as smooth as if they had been
chiseled off, separated by edges or by distinct angles ; which offer every
indication of being fragments or broken stones, of course lead us to suspect
the reverse. This mere glance however gives mere presumption only, and
does not permit us. to dispense with other examination. We are therefore to
carry in the scoop or the finger within the cavity of the organ, to know
exactly hov/ the case stands, and so as to withdraw every tolerably large
sized piece of any foreign body. Some bladders, in fact, contain a very con-
siderable number. That of a patient who had been cut three times contained
three hundred at the time that M. Ribes made the examination of his body.
Recently the journals have mentioned a patient from whom M. Roux ex-
tracted near a hundred; and in another M. Murat counted six hundred
and seventy-eight. It is of vital importance that none of these calculi remain
either in the bladder or in the trajet of the wound. As they are usually very
small they may very easily lose themselves amongst the parts, and that
unless the most scrupulous minuteness of observation be used the patient
will run the risk of preserving about him the nucleus of stone after the ope-
ration. The size of the stone may also become a source of embarrassment.
When they exceed two inches in their small diameter, it is often impossible
to extract them, even by tlie recto-vesical cutting. In a case of this kind
last year, M. Dupuytren performed the operation of lateral cutting, and
slit up the anterior wall of the rectum. Divers instruments have been invent-
ed to break them into fragments in such a case. Tiiat of brother Come has
two pyramidical teeth within the grasp, which is flat- filed. The stone-break-
ing forceps of Benj. Bell, are also denticulated, and a screw crosses the
handles. M. Sirhenry's forceps for breaking the stone, by penetrating
per urethram; the **pince a virgules" of Baron Heurteloup; the friction for-
ceps of M. Rigaud ; the *' ansebrise" of Jacobson ; in a word, almost every
forceps used in midwifery will accomplish the object. The latter instru-
ment would possess the advantage of allowing of the perforation of the
stone, if their ordinary construction did not permit us to break them, and
should I think be preferred ; but the stones which render such manipulation
indispensable, are so large and difficult to embrace that it is generally
thought preferable to proceed at once to the operation of hypogastric cuttingy
and extract them above the pubis. No one is now so fearful of seeing a
stone when friable break beneath the forceps, as to employ Broomfield's
quadruple forceps, the graduated ones of Lecat, the horsehair fillet of Huss,
Home's circular development forceps, or the triple forceps with fenestra in
the grasps made by Cluly, the cutler in Sheffield. If the thing occurs it is
found more convenient to go successively in search of all the fragments with
the same instrument, and wash away the fragments with emollient injections
afterwards.
OPERATIVE SURGERY. 775
Hie state of fixedness of the stone has been at every period a source of
more embarrassment with surgeons. Before we lose ourselves in useless
eiforts we should try with the forefinger to detect the nature of the difficulty
which exists. If the foreign bodies seem to adhere by one surface only,
probably some fungous growths and vegetations have sprung up between its
roughnesses. In this case, the plan of Lapeyronie, followed hj ^larechal, Le
Dran, M. Boyer, &c., which consists in methOilically pulling at the stone
with forceps when once it is seized, to tear it away ; is the only one which
will answer every time that the finger or scoop fail to shake it from its attach-
ments. If it is simultaneously encysted and adherent, rubbing away the cyst
with a staff, advised by Littre, will be of very little service. Scarcely better
would pounding it with forceps, which he also advises, prove to be ; laceration
here is equally the only remedy. When simply stopped by a frenum, or
contained in a cyst more or less largely open, and not adherent, a cutting
instrument should not always be forbidden ; Garengeot, Le Blanc, and De-
sault have used it with success. A straight, or curved probe-pointed bis-
toury, surrounded with a strap of linen round its edge, to within five or six
lines of the button, should be very cautiously carried to the free border of
the cyst; then introduced flatwise between the stone and the cyst, so that as
its blade is withdrawn it may cut the adventitious sac from top to bottom
to a suitable extent, almost as if we were relieving the stricture in a hernia.
Nothing prevents this operation from being performed on other points of the
frienum, if the first does not suffice, or it appears too dangerous to extend it
far enough.
The tonsil kiotome, or frenotome, used by Desault, certainly is not equal
to the bistoury of Pott, and does not deserve adoption. The common straight
bistoury employed by Garengeot, offers two inconveniences; 1st, its point
incessantly threatens to cut the wall of the bladder; 2d, it neither slides, nor
can be introduced as easily between the cyst and the surface of the stone, as
the bistoury which is probe-pointed. The surgeon should however remember,
that a frenum formed by simple partial contraction of the urinary pouch,
and that abnormal sacs existing with it, instead of projecting inwardly will
not admit of such incisions at all, or only with the utmost reserve ; for as they
then bear on the inner surface of the bladder itself, this would seldom fail to
injure the peritoneum.
An exception should still be made in favor of calculi fastened by one end
within the ureter. The orifice of this canal, which crosses the thickness of
the bas-fond of the bladder very obliquely, might in fact be incised separately
for an extent of several lines without any danger.
It is better to return to force, shaking and tractions in various directions,
if a stone of a gourd-shape for instance be retained b}^ one end in the ureter
or in a secondary cavity of the bladder, and only have recourse to incision
when in despair of succeeding in any other wa3'.
Cutting at Two separate Times. — The difficulty of seizing, or extracting the
stone, the dread of exhausting the patient by fatigue from long searches, have
led to this idea of practising the operation at distinct intervals ; that is to
say, at one to confine oneself to merely opening the bladder; to put off the
other till tiie extraction of the stone. The same idea had been set forth by
the Arabs, for which Albucasis says, that if the hemorrhage comes on, the
774 KEM ELEMENTS OF
surgeon is to touch the wound with vitriol and wait^ F^-anco, who re-e&tab-
lished it, waited for three or four days. Maret, of Dyon, nevertheless,
is the first who endeavored to render it general. Since then it has
received the support of Camper, of T. Haaf, who returned to the search
after a lapse of eight days, and more lately of M. Guerin of Bordeaux. It
is doubtless to be expected after its adoption, that at least the foreign body
will approach the passage made for it and be reached with less difficulty ; and
even, that it will escape by the wound, and fall into the dressings. But in
spite of these advantages, there is to be endured the restlessness of the
patient, the ceaseless irritation of the stone, the acute pain produced by the
passage of the forceps through a wound more or less inflamed ; in a word,
two operations instead of one. Consequently modern practitioners have
rejected this form of operation, and never, unless it is impossible for them to do
otherwise, leave a stone in the bladder after having once divided the soft parts.
Injections. — For fear that some gravelly fragments may still remain behind
in the bladder, most surgeons are in the habit of washing it out by large injec-
tions of warm water or emollient decoctions. When carefully effected,
injections can never do harm. Nor do v, e see how they can be dispensed
with, for they have the undoubted advantage of bringing with them clots of
blood, flocculi of mucus, as well as fragments of stone, which often evade the
most attentive scrutiny. To exhibit them we require a large syringe, a common
glyster syringe, which will contain a quart or more of fluid. With less the gush
of the injection would not be forcible enough to expel the matters which we are
anxious to expel. Not to wound the organ we may use a syphon ending like the
top of a watering pot, either of tin or of gumelastic. However, with a little dex-
terity and an unrefractory patient the common pipe exposes him to no risk.
After the first injection a second, and then a third, are made so as to be yet
more sure of detecting heterogeneous matters. We are then to wipe off the
patient with a sponge and some warm water, and remove the ligatures
and other fetters which the operation may have rendered necessary. The
patient is then placed in bed upon his back, his head and chest moderately
elevated, the lower limbs close together, semiflexed, and kept so by a sheet
folded cylindrically and placed under the hams. Tying the legs and thighs
of the patient to prevent them from separating, as was done only as late as
the last century, is a useless proceeding. Even the supine position need
not be permanently maintained. The patient must be allowed to lean on
either side, and confine himself to his back only so long as it is not incon-
venient or attended with fatigue.
The Cannia in the Wound. — The practice of placing a catheter in the
bladder, the more quickly to re-establish the natural route of the urine,
has long been discontinued. The same is nearly the case witli the
canula, which many operators once thought it necessary to leave in the
wound for a certain number of days after the operation, and which was
intended to prevent infiltrations by conducting out the efiused fluids. This
tube, which some practitioners are still in the habit of using under certain
particular circumstances, irritates the wound, the neck of the bladder, and
also its lining membrane. It is a foreign body thwarting the restorative efforts
of tiie organization, a greater or less annoyance to the patient, and which
alone may give rise to fearful symptoms. I once saw it used in an old man
OPERATIVE SURGERY. 775
eighty-four years of age who was soon attacked with adynamic symptoms,
and who died at the end of eleven days. The whole length of the wound
was covered with a grayish concretion ; pus was poured out round about it,
and traces of purulent inflammation were discernible even within the pelvis.
Thus it is an instrument more hurtful than useful ; and if it should ever be
an object to guard against approximation of the edges of the incision, it would
be better to place a tent or pledget of lint between them.
Untoward Occurrences, — The first accident to be feared m lateralized cut-
ting in general perineal lithotomy is hemorrhage. This may occur under
three circumstances ; during the division of the tissues, in the four and
twenty hours subsequent to the operation, and after a lapse of several days.
In the first case it must be owing to lesion of the arteria superficialis, the
arteria transversa, the hemorrhoidal, or trunk of the pudic artery of the pros-
tatic plexus of veins, or else of some anomalous artery. It comes from the
.superficial when the blood springs from the upper angle of the wound and
•subcutaneous layer; from the transverse on the contrary if it can be stopped
,Lby pressure with the finger some way dov.n on the outer lip of the wound
^opposite the bulb and membranous portion. It is caused by the hemorrhoidal
i4f the stream comes from the lower angle of the solution of continuity. It is
'•likewise backward and outwards when the pudic has been cut, but its source
will be perceived at a great depth. That bleeding which results from dividing
a vein, or which is caused by the section of some artery around the prostate
being more deep-seated than any other, will in the former event be known by
the color of the blood, and in the second by the circumstance that no pressure
on any part of the perineal wound with the finger will arrest it even for a
moment. When the blood does not flow per saltern, and is not in sufficient
abundance to weaken the patient much, no obstacle should be offered to it-
It is frequently a salutary loss, and capable of warding off serious evils. On
the other hand, if threatening to be abundant, to be lasting, when the patient
is already much weakened, or very aged, it is proper to check it at once.
When it can be applied, ligature is the best and most simple means for the
purpose. W^hen the divided trunk can be seen in the wound it is to be seized
\vith a pair of dissecting forceps, or if not sufficiently isolated with a tenacu-
lum and a thread immediately passed around it. If it were the pudic we had
to tie, and its extremity difficult to seize, we should, I think, imitate Dr.
Physick, who cut it in his first operation for stone, and pass between it and
the ischio-pubic ramus a double thread by the assistance of a curved needle
in the handle contrived by J. L. Petit. This needle should be buried in the
interior of the wound, would pass on the outerside of the artery behind its
division to re-enter the solution of continuity, where the thread is to be dis-
engaged from its point so that it may be withdrawn, and immediately be
knotted over the tissues. I do not think that the advice given by Mr. Tra-
vers of carrying in such a case a ligature round the vessel as it passes between
the sciatic ligaments can ever be thought of. Besides, this wound is so un-
common, so difficult to inflict, unless we depart widely from the rules of
scientific surgery, that the means of guarding against the danger from it are
of minor importance. It is also probable that persons have been frequently
misled as to its existence by bleeding from anomalous branches, or from some
cf its secondary branches rather larger than common.
776 NEW ELEMENTS OF
Supposing it were easy to isolate and seize the vessel, but that it was too
high up for us to surround it with a ligature easily, we should not hesitate to
twist it by means of the forceps which have hold of it. Lastly, if neither
torsion nor ligature can be applied, or entirely fail to arrest the hemorrhage,
several other means are to be tried. The large canula, so arranged as to
fill and press upon all the extent of the wound, in use not half a century
ago, was inconvenient from compressing more strongly towards the skin than
the prostate, and frequently causing effusion of fluids into the bladder. It
appears that M. Boyer has frequently advantageously used a strong roll of
lint carried within the bladder itself and fastened by a sti'ing, the two ends of
which are then knotted to another roll which is passed down as deeply as
possible on the same side as the urethra ; but the little contrivance of M.
Diipuytren is here evidently the preferable one. It consists of a tube open
at top and on the sides, around which is attached a sort of shirt made of fine
linen. It is introduced in beyond the neck, and then we are to slip between
it and its linen covering some lint with a pair of dressing forceps until the
wound is quite full, so as to compress all the circumference suitably, rather
more strongly towards the bottom than near the skin. All this being retained
by a T bandage, offers no impediment to the flow of urine, and moreover
hIIows us to increase or diminish the pressure in one or another direction as
may be requisite. In two or three days the surgeon gradually takes out the
lint, and soon afterwards the rest of the apparatus.
If the bleeding does not show itself for some hours, it is seldom a source
of so much uneasiness as to require instrumental attention. The blood which
now appears had not appeared at an earlier period, not because the contact
of the air had for a moment constricted the vessels, nor because of any spasms
of these canals, but because the general circulation usually very slow in the
patient when stretched on a bed of pain, experiences a lively reaction, a re-
newal of power in its impulsive efforts ; and therefore it is that the evil often
cures itself, and that this hemorrhage is easily suspended by the application
of cold or revulsives, which tend to draw the fluids into another direction.
In such a case we might begin by applying cold to the hypogastrium, the
upper part of the thighs and perineum, and even by injecting it into the
wound. If there be fever and a hard pulse, a small bleeding from the arm
is evidently indicated. In a contrary condition of system, manuluvia of
mustard, dry cupping, scarifying between the shoulders, mustard plasters to
the same regions should be tried before tamponning or the ligature, unless the
hemorrhage was profuse in the extreme.
When it does not appear for some days we may be pretty certain that it
results from no opening of an artery, but from pure exhalation either from
the wound or vesical cavity. To account for it on a contrary opinion we
must suppose the separation of some eschar from the vesical parietes, or, as
in fact is sometimes seen, general debility, decided dissolution of the fluids
which has softened all the sanguineous clots, and broken down every barrier
opposed to the exit of the separative fluid. It is therefore to be considered
as the most dangerous. It admits of no other treatment than that advised
for the preceding ones.
Wowids of the Intestine. — If the rectum is wounded in the first stage of
the operation, or in any way before the bistoury has cut the neck of the blad-
OPERATIVE SURGERY. 7 ft
der, the wound is always found beneath the prostate gland. It most frequently
occurs in withdrawing the lithotome, and then the perforation has its seat at
a more elevated point above the sphincter. Frequently it is not first per-
ceived. It may even happen that at first the perforation was not complete, bu£
that the wall of the rectum, previously much thinned by the tutting instru-
ment, is bruised, and irritated during the extraction of the stone, and that
the fall of the slough completes the misfortune. This at least seemed to be
the case with a patient whom I saw operated on at the hospital St. Louis, in
1822. In the first of these events, i. e. when it is known directly, either by
the escape of gas, or the passage of fecal matters or urine, that the rectum is
wounded, and the division is extensive enough to induce the belief that it will
end in fistula, the best way to prevent its occurrence is to slit the end of the
perineum and of the intestine to the anus. Contraction of the sphincter being
no obstacle to the free passage of the matters, the wound generally heals up
kindly, and almost as quickly as if nothing uncommon had happened.
In the second event — that is, when some days elapse, and there be or be
not any loss of substance, vesico-rectal fistula is already formed, and it is
not impossible that it may disappear spontaneously — we should wait the ordi-
nary term of the cure, and afterwards treat it as if it had resulted from any
other cause. Urethral fistulae, properly so called, are now very rare, though
still sometimes seen ; but whether they extend directly outwards, or only
communicate externally by the intervention of the anus, their treatment is
the same as that of urinary fistula, which will be discussed in a separate
article.
Paralysis of the Bladder. — Retention of urine, caused sometimes by clots
of blood, swelling of the wound, inflammation of the cervix vesicae, or of the
prostate syncope, convulsions, incontinence of urine, inflammation of every
sort which may show itself during or after cutting for stone, require no fur-
ther ti'eatment than that generally known and followed in the case of these
diseases. The wound is a longer or shorter time in closing. The urine flows
through it entirely for two, three, four, or five days ; and then the patient,
from time to time, experiences the inclination to void it. At length some
drops pass through the urethra. More then comes through it, and ultimately
it passes entirely by the natural outlet from the fifteenth to the thirtieth day.
From that time, the perineal opening has entirely healed. However, it is not
uncommon to find them follow other routes in tlieir exit. In some they con-
tinue to escape by the wound for two, three, four, even five and six months, so
that the wound may in reality be considered as a fistula. In others,
again, the wound in the perineum closes directly, or in eight or twelve days.
In America, Drs. Physick, Dorsey, and Copeland have each seen an example
of this occurrence. Beclard has seen several, following the bilateral cutting.
Few experienced operators have not seen cases, but few have mentioned so
large a proportion as M. Clot d'Abou Zabel, either after lateralized cutting,
or the median cutting of Vacca, of which he quotes eleven cases.
Art. 2. — Recto-vesical Operation for Stone [Posterior or inferior).
The pains which surgeons in all ages have taken to avoid wounding the in-
testinum rectum, in the performance of lithotomy, is of itself suflicient to
98
77S ' NEW ELEMENTS OF
prove how very far they were from wishing to establish this method as a prin-
ciple. It is accordingly but of late years that the idea has suggested itself
to practitioners, and M. Sanson, who first ventured to promulgate it in 1816,
found in this time-hallowed prejudice, one of the most powerful opponents to
the adoption of his w^ay of thinking. It is now found out, that the extraction
of stones by the rectum is not an entirely new practice. M. Jourdan, amongst
others, has noticed that Vegetius, a veterinary surgeon mentioned by Mai-
ler, had said in a work published a century before at Basle, " jubet per vulnus
recti intestini et vesicas aculeo lapidem ejicere." A mention made by frere
Come, of a patient who had a recto-vesical fistula caused by stone, and who
recovered after the foreign body was extracted through the gut, may alsp have
served as the basis of M. Sanson's theory. The splinter taken out of the
bladder by enlarging the fistula in the rectum by Camper, is a new proof
which might have been made available. It is, moreover, very well known,
that Desault at the Hotel Dieu very frequently cured recto-vesical fistulas
by cutting the sphincter ani through, so as to create a wound which should
extend all the way to the perineum. It must be added that, according to the
statements of Dr. Clot, recto-vesical cutting has been practised in Egypt from
time immemorial ; he has seen it performed by empirics who are very numerous
in that country,' and whose knowledge had been handed down from father to
son like a family estate. However, as no one among us had established the
procedure as a regular one, of going through the rectum in search of calculi
ia the bladder, M. Sanson deserves to be fairly considered as the inventor of
" recto-vesicaP^ cutting. His method, which was never much advocated in
France> England, or Germany, was in Italy almost at once adopted by several
surgeons of distinction, among others by Vacca, Barbantini, Farnese, Giorgi,
Guidetti, Giuseppe, Lancisi, &c. The advantages ascribed to it by its in-
ventor, are those of being more easy, less painful, of opening the bladder in
the largest direction of the pelvic strait; of exposing no artery to be wounded,
and of allowing of the extraction of the very largest calculi. But with us,
the dread of being unable to close up the communication between the gut and
the bladder after the cure, has weighed against every other probable advan-
tage. Indeed, up to this period this operation for stone has not been per-
formed in our country above some thirty times by MM. Sanson, Dupuytren,
Peserat, Castara, Willaume, Cazenave, Dumont, Taxil, and some others.
We shall be enabled, after a survey of the parts which the insti'ument must
encounter, to judge of what hopes may reasonably be founded upon it.
§ 1. Anatomical Remarks.
In all the different procedures thus far advised, the cutting instrument acts
only in the interspace which separates the body of the bladder of urine from
the membranous portion of the urethra as it enters the horizontal aponeurosis
of the pelvis. It is therefore this part of the urinary passages, and that part
of the rectum which answers to them, which it is particularly necessary for a
surgeon to know.
The Bladder considered in its posterior wall, offers its trigonal space whose
base usually looks towards the recto-vesical cul-de-sac in the peritoneum,
and at its lateral angles receives the terminations of the ureters. The length
OPERATIVE SURGERY. 779
of this trigone vesical is from twelve to fifteen, or eighteen lines from before
backwards, and usually two inches across. On the median line, it is only
separated from the rectum by a dense lamellar tissue, which expands as it
goes towards the sides, where the vesiculae seminales, having the vas-deferens
on their inner edge, come, converging towards its anterior angle to divide it
from the rectum, and push it a little forward. Its anterior angle, which forms
the entrance of the urethra, at the instant of its engaging in the prostatic
cone, give origin to the uvula vesicae, or luete vesicale, which continues for-
wards under the appellation of crista urethraliSy and afterwards under that of
verumontanwn.
That portion of the urethra which follows it, is especially remarkable as
connected with the seminiferous tubes and the prostate itself. These canals,
which open sometimes nearer, and sometimes rather further from the median
line, but in such a way as never to be more than a line apart from each other
in a natural state of parts, and often blending, as it were, upon the free edge
idf tiie verumontannm, diverge thence and insensibly separate as they
approach the termination of the vesiculae seminales; that is to say, as they
come towards the inferior and somewhat lateral surface of the point of the
trigonal space, where they are four or five lines apart. The prostate gland just
here presents frequently at its inferior surface a sort of groove which em-
braces the front of the rectum. The ejaculatory canals cross the prostate
from behind forwards, from within outwards, and a little downwards from
above. Its thickness upon the median line, is only, as we have seen already,
from five to seven or eight lines, and sometimes less. Lastly, its posterior
edge extends, in certain persons, from three to four lines back of the urethra
under the trigone, so as to form a knob there, the importance of which will
hereafter appear.
The rectum, which is movable, and maintained in front of the os sacrum
by its peritoneal reflection, a little to its left in the upper part, presents no
interest until it descends far enough to apply itself to the anterior surface of
the coccyx. There the peritoneum leaves it, to mount up behind the blad-
der, and to line the recto-vesical excavation. The intestine continuing to
advance obliquely and downwards, enters into contact with the vesical tri-
gonal space, with the ends of the ureters, with the vesiculae seminales, and
with the vasa deferentia. When it has got beneath the prostate, and upon
the point of the coccyx it is enveloped in the ring of the sphincters, of the
levator ani and coccygeus muscles; it changes its oblique direction to
become vertical, and end in the anus. As, on the contrary, the urethra at
this point leaves the axis of the body to pass forward, so there naturally
results a larger or smaller interspace between this canal and the rectum; that
interspace of which we took notice above; and which after its two principal
limits — I have thought might be called redo-uretral or bulho-anal triangle.
There are eight or twelve lines from the opening of the anus to the top of the
prostate. Before we reach the tubercle on the uppermost edge of this gland,
is a distance of an inch and a half to two inches : the peritoneal cul-de-sac
being separated from it only by an interval of twelve to fifteen lines, some-
times of six or eight lines merely, as I have seen in two subjects, as M . Senn
has seen it only two or three lines in width. In a normal state in the young
subject, the rectum begins to contract at the moment it passes behind the neck
Tffd NEW ELEMENTS Or
df the bladder, and above this point forms merely a cylindrical canal of
gi'eater or less size. In advanced age, or in persons of a habitually costive
habit, a different disposition is frequently remarked
In the first place this intestine may oiFer a large excavation, -which has
more than once been seen to extend on either side of the prostate and trigone
vesical, so as almost to come under the edge of the knife in cutting for stone,
either lateralized transversal or even completely lateral. In the second
place it may also enlarge anew after it has passed beyond the posterior edge
of the prostate before it clears the sphincter externus, as if to form between^
the anus and urethra a cul-de-sac, which in traversing the recto -urethral
triangle in bilateral cutting it may be difficult to avoid.
The parts, though few, which exist between the bladder and intestine,
deserve perhaps a passing mention. There are no vessels on the median
line, and the cellular tissue at that spot is almost always destitute of fat.
Laterally these two organs being, by their rounded form, drawn in opposite
directions must leave two sorts of furrows, larger as we approach nearer the
parietes of the pelvis. These furrows contain, besides the vesiculss seminales,
vasa deferentia, and ends of the ureters, and below the posterior angles of
the prostate, an exceedingly lax lamellar tissue, particularly outwardly, where
it is continuous with the rest of the pelvic cellular tissues ; oftentimes some
fat, some arteriolse and vesicles which pass upon the sides of the neck of the
bladder and the forepart of the intestine.
§ 2. Methods of Operation.
Upon this principle, M. Sanson ascertained that recto-vesical cutting might
be performed in two distinct ways ; one in which the prostate, urethra, and
inferior extremity of the rectum alone are divided ; another, in which at the
same time the bas-fond, or rather the trigone vesical, and the intestine are
attacked, so as to save the two anterior thirds of tlie gland. In Italy, Vacca
and M. Barbantini decided at once upon the former, so as in a measure to
' appropriate it to themselves. Geri, Guidette, &c. attached themselves to
the second way, on which M. Sanson himself had laid most stress. Upon
the whole, there is no great difference in performing them.
Procedure the first. — The staff held by an assistant is to press accurately
upon the median line, so as to depress the anterior face of the rectum. The
surgeon introduces the left forefinger to a depth of ten lines into the anus;
turns the pulp forwards and the nail backwards; slips in flatwise upon this
finger a sharp bistoury two inches long; plunges its point into the groove of
the staff, having first turned its cutting edge upwards ; then he raises his right
wrist and cuts from behind forwards, that is to say from anus to urethra, the
lower part of the sphincter externus, and also all the parts contained in the
recto-urethral triangle, drawing his bistoury with strength towards the bulb.
He then seeks to recognize at the bottom of the wound the point of the
prostate, and places his finger upon the groove of the staff* through the mem-
branous portion of the urethra, its cubital edge being towards tlie symphysis
pubis, the nail towards the left ischion. The same bistoury, held like a pen,
18 then plunged into the groove of the staff, and slid along it into the bladder.
It is then withdrawn, lowering the hand a little, so as to divide almost the
OPERATIVE SURGERY. T9t
whole of the prostate, and such soft parts as may have escaped in the first
incision. By this means the sphincter externus, the interlacing of the fibres
of the transversi and bulbo cavernosus muscles, the seat of junction of the
fibrous laminae of the perineum, the membranous portion of the urethra, the
prostate from top to bottom on its lower surface, and the forepart of the
rectum beneath the trigonal space, are divided. One ejaculatory duct also is
likewise comprehended in the incision, for chance alone would so unerringly
direct a bistoury on the median line as that it should pass directly between
them. If, as is easy enough to happen, the incision deviate to one side, it
will soon strike upon a distant part of this canal, and might even touch the
end of the vas deferens, or even on the inferior end of the vesiculae seminales
of the same side. No considerable artery presents itself, not even the
abnormal branches indicated when speak'ng of cutting through the perineum.
The Italian professor advises instead of the procedure of M. Sanson, that'
the index finger be so applied upon one surface of the bistoury, the handle of
which is enclosed in the hand, as that its fleshy part pressing a little upon the
instrument may entirely cover its point; that it be carried in this way to the
required depth ; that when this is done, the cutting edge of the bistoury be
turne^^orwards, so that the finger may be placed on the back of the blade,
and the section of tissues performed at one stroke, as was before stated. The
left fore-finger remaining unengaged feels for the groove in the staff, in order
that the bistoury, whose cutting edge must then look downwards, may be
directed on the membranous portion of the urethra, and from before back-
wards; that is to say, in an opposite direction to that which until then it had
pursued to cut the prostate and tubercle at the vesical orifice.
Procedure tlte Second. — The first incision, which is commenced rather higher
up, does not end as near the bulb of the urethra as in the first procedure.
The left fore-finger pressed into the wound no longer seeks to recognize the
point of the prostate but its "base; and the bistoury to strike the groove of
the staff is to be passed in on a level with its posterior edge, or at most of its
two lower with its upper third. It is then pushed on into the bladder, so as
to open the inferior wall for about an inch by withdrawing it from before
backwards and rather downwards from above. The solution of continuity
involves, when this method is adopted, the same parts as the preceding, so
far as the first incision is concerned. The second stage of the ope-
ration on the contrary saves a portion of the urethra and of the prostate
at the place where the seminal canals touch, and which they cross, wounds
instead the trigonal space, and approximates nearer the recto-vesical excava-
tion. Should the incision not be exactly in the median line, it .may involve
the ejaculatory ducts, the seminal vessels, the vasa deferentid, and even if
tiie deviation is very great, the ureter. It is evident also that the peritoneum
runs great risk, and that if it dips down lower than common it will not
escape. It must be remarked also, that according to the direction given the
bistoury as it is withdrawn, the wound should be more of the bladder than of
the rectum ; be much longer consequently above the inner surface of the first
than the second of these organs ; so tliat the mucous membrane, and a large
part of the fleshy membrane even of the rectum, comes down in the form of a
valve several lines beneath the wound in the bladder. Some Italian surgeons
endeavored to perfect M. Sanson's operation by placing some dilating instru-
782* NEW Elemi:nts of
ment within the rectum. M. Geri, for example, had contrived a large gorget
for this purpose. At first, this modification did seem to fulfill the end of
guarding against this movableness of tissues^ against which M. Pezerat had
so much difficulty in struggling in the recto-vesical cutting which he per-
formed, and to render its incision nearly less difficult. However, Vacca
opposed it very violently, and it is indeed soon seen by reflection that it
must needs augment the difficulty of the operation.
But lithotomy per rectum is not alone to be objected to on account of the
difficulty of its execution; and no amelioration proposed in this respect deserves
any very great attention.
We can, I think if it is wished, estimate the value of the recto-vesical
operation for stone without difficulty. Its greatest and most indisputable
advantage is that it guards wholly against hemorrhage : first, because there
are no vessels naturally located between the parts which are divided : secondly,
because no vessels springing from anatomical anomalies, have ever been de-
tected in them. The second advantage is, that it is extremely simple. But'.
upon this point let us not be deceived. Division of the mucous membrane
of the anus, rectum, and posterior portion of the perineum, is in certain
persons attended with all the difficulty of which M. Pezerat speaks, whatever
precautions may have been taken to make tense the tissues.
In the third place, it may be urged as an objection to those who attribute to
it the making of so easy an exit for the urine, as that infiltration is never to
be feared ; that the recto-vesical septum being pulled about by the instruments
or the stone during the operation, is of such a nature as softietimes to detach
itself, and then we can see nothing to render infiltration of some drops of
urine into the surrounding cellular tissue impossible. Besides which, this
infiltration almost necessarily occurring above the pelvic aponeurosis will
very soon spread to all the sub-peritoneal cellular tissue of the organ.
Its advantages of allowing passage to enormo,us calculi, and of admitting of
a very extensive incision, may with equal propriety be disputed. In my
opinion it is a serious error to attribute this difficulty to the degree of separation
between the bones. No more than Scarpa can I conceive how, in any method
of cutting the inferior strait when of regular formation can impede the
extraction of a stone. The difficulty always arises from the opening into the
bladder. When this is made only upon the bas-fond, it is not possible to give
it an extent of more than twelve or fifteen lines, because there is this distance
only between the prostate and the peritoneal cul-de-sac. What, then, is the ad-
vantage, when we can obtain, in bilateral cutting for example, an opening of
from fifteen to twenty lines ? If the incision is confined to the prostate with
the hope of exceeding its bounds, the division, supposing it at its extreme
length, can be only eight or twelve lines. If we go beyond this, necessarily
we exceed and cut the edge of the gland, since in this direction its radius is
but six or seven lines. Were the two procedures to be combined, the opening
might be of an extent of an inch and a half or a couple of inches. Thus far,
this has not been proposed by any one ; and besides, the bilateral cutting
again is calculated to produce a very extensive division. Finally, if the rule
be po longer adopted which advises us to confine the incision to the circle of the
prostate, it is evident that by the bilateral method we can cut the neck of the
bladder on either side, and so produce a wound of two inches or two inches
OPERATIVE SURGERY. 785
and a half wide ; which it would be impossible to do on recto-vesical cutting,
unless bj a voluntary exposure of the peritoneum.
It appears that in speaking of this operation something has been attributed
to the division of the perineum and membranous portion of the urethra.
The same error, moreover, occurs in almost ever j discussion relative to the
other methods of cystotomy. But it is easy to satisfy oneself, that the enlarge-
ment of the posterior opening of this canal alone can enter into the account*
Enlarge it directly backward, and you never will obtain more than an opening
of seven or eight lines without going beyond the prostate, whether your ex-
ternal incision is confined to the perineum or whether it at the same time
comprises the extremity of the rectum. If you prolong it an inch or an inch
and a half, you will cross the whole length of the trigone vesicale, and give
your wound only an extent of two inches, while you incur the utmost risk of
cutting the peritoneum. On the contrary, the double oblique incision allows
of our going as far as twenty and some lines over without encroaching on the
summit of the bladder, and if we are not afraid to exceed the prostatic limits,
it may be yet much further increased evidently than by the posterior method.
As to injury of arteries, it is well to inquire if it can counterbalance the
danger of recto-vesical fistulae.
In transverse cutting, it is almost certain that bleeding will not occur
once in a hundred times. Recto-vesical cutting is followed by fistula urinaria
at least once in four or five times.
The hemorrhage is far from proving always fatal. Fistula is a disgusting
infirmity ; for the most part an incurable one.
So far recto-vesical cutting has been followed by almost as great a propor-
tion of deaths as the operations performed upon the perineum.
It has the special disadvantage of inevitably cutting one of the ejaculatory
ducts. Experience proves that it is often succeeded by swelling and other
serious disease of the testicles. The peritoneal reflexion had been opened
into in one of M. Geri's patients. Out of six, M. Janson of Lyons lost
two ; in whom the intestine was acutely inflamed. It is stated by authors
that the bladder is often inflamed owing to the entrance of stercoraceous mat-
ter into it. Scarpa states that in two patients seen by him, it was gangrenous.
The vesiculae seminales have also been opened into. Abscesses ^vithin the
pelvis have many times been met with. In short, out of one hundred opera-
tions performed in this way up to the present time by MM. Sanson, Dupuy-
tren, Camoin, Pezerat, Willaume, Cazenave, Dumont,Urbain, Sanson, Taxil,
Barbantini, Vacca, Geri, Guidetti, Farnese, Giorgi, Giuseppe, Cittadini, Mori,
Lancisi, Castaldi, Cavarra, Regnoli, Baiidiere, Sleihg, Clot, and Wenzel,
twenty deaths are enumerated, as many fistulas, and other occurrences which
have endangered the lives of some of the patients.
Upon the whole, recto-vesical cutting seems to have no real advantages over
bilatei-al cutting; so much so, that if it were decided that the latter was in-
sufficient, it would perhaps be better to cut above the pubis than through the
rectum.*
* I have been equally unsuccessful with M. Civiale in ascertaining whether it be true, as M.
Wessely assured me it was, that vesico-rcctal cutting had been invented in Germany in
1813.
784 NEW ELEMENTS Of
Art. 3. — Hypogastric Operation for Stone.
The idea of opening into the bladder above the pubis, for the purpose of
removing calculi from it, is not formally expressed by any ancient author. It
appears certain that Philagrius of Thessalonica, in advising an incision '^sm-
perne juxta glandis magnitudinem/^ meant merely to speak of calculi which
were stopped in the urethra, and that his only object in opening the back of
the penis was to prevent fistulae, which were much more to be feared from
cutting into the inferior wall of the excretory duct of the urine. On the
other side, I do not see upon what authority Mr. Samuel Cooper thinks that
the operation performed by M. CoUot, 1475, has any reference to hypogastric
cutting rather than to nephrotomy, or to any thing else which he pleases. The
merit of it incontestably belongs to Franco ; however, this surgeon was induced
to do it from necessity in spite of himself, and sedulously forbids others to fol-
low his example. Rousset or Rosset, in 1581, who gave a labored description
of it twenty years after the publication of Franco's book on the subject, is
consequently the first person who positively recommended and endeavored to
establish its general adoption as an operation. Still, from what he says, it
might almost be supposed that other practitioners cotemporary with him had
likewise alluded to it. Be this as it may, Henry III, who had promised to
give into his hands three or four criminals as an experiment, having died,
Rousset could never perform it on the living subject ; and since him no one
seems to have thought of it, until 1635, in which year Mercier defended it
before the Faculty of Paris, in a thesis by Nicolas Pietre. At length
some surgeons adopted it, and Collot relates that in 1681 Bonnet performed
it before Petit at the Hotel Dieu with entire success. Proby, failing to extract
a stone by the usuai methods, had likewise recourse to it some years after-
wards ; and Groenvelt publicly advocated it in a work published in London
in 1710. So little was it generally known, however, that Douglas of Dublin,
in 1718, for a short time considered himself as its discoverer. The success
derived from it by the last named surgeon, having opened the eyes of the
profession, and forthwith engaged the attention of Cheselden, Macgill, Thorn-
hill, Middleton, Bamber, and Pye, in England ; and of Morand, who per-
formed it at the Hospital of Invalids, May 27, 1727, on an officer sixty-eight
years old, and saw it done on the 10th of December following at St. Germain
en Laye by Berier on a child named L. Amon, four years of age. It was
likewise practised by J. Robert, Sermes, Kulmus, Heuermann, and particu-
larly by Heister, who caused it to be defended in a thesis sustained by Weise
at Helmstadt on the 8tli of December, 1728, and who obtained reports of
cases of it from Runge and Praebisch, so that it seemed almost about to meet
with general adoption. Cheselden, in 1727, had' performed it upon six
patients with the loss of only one ; Douglas, with a similar loss out of nine
persons who underwent it ; Thornhill lost tv/o persons out of twelve ; Mac-
gill one in four. Notwithstanding the numerous eftbrts excited by the
appearance of frere Jacques's method, this operation was soon abandoned
and it had almost ceased to be thought of when frere Come in turn un-
dertook its readoption in 1775. Since then it has been advocated by Leblanc
* OPJERATIVE SURGERY. f^S
of Orleans, and Bazeilhac, and Lassus, and also MM. Deschamps, Dupuy-
tren, Roux, Boyer, de Guise, and several others have performed it, but
merely as an exception and not as a general rule. Notwithstanding every
defence made for it, and the numerous instances of success obtained in France
by M. Souberbielle, tlie inheritor of the principles of Come and Barzeilhac,
the high apparatus relapsed into dis-use, until, ovv^ing to some proposed im-
provements by MM. Scarpa, Dupuytren, Sir Edward Home, and Gelher it
has a third time been attempted to set forth its advantages, and to substi-
tute it for the perineal methods of operating. It consists in an incision of the
anterior surface of the bladder through the wall of the abdomen.
§ 1. Anatomical Remarks.
In all the operations for stone done by the lower apparatus, the instrument
can arrive at the bladder only by exposing very important organs to injury ;
and such is the distribution of parts, that tliey will not always allow of an
opening large enough to permit the passage of bulky stones. On the contrary.
It seems that by opening into the bladder through the hypogastrium, there is
scarcely any risk to be apprehended, and that it will always be practicable to
make the Incision of the tissues of any required dimensions.
The empty bladder, taken together, forms in the adult male a conoidal
pouch, whose summit extends through the medium of the urachus tov/ards
the umbilicus ; and whose base descends upon the rectum, forming a curve
below the pubis to give origin to the urethra. It has often since the time
of Celsus been repeated that it inclines a little to the right. The ancient
latin dogmatist having confined himself to this simple assertion on the subject,
some of his commentators suppose that the summit, and others that the fundus
is to lean towards the left. I, like my predecessors adopted this same idea
of the inclination of the bladder in an earlier work ; but I have since satisfied
myself that the appearance has been taken for the reality. The urachuf*
invariably terminates its summit, and the urachus is invariably placed behind
the median line. Again, the urethra is placed exactly in the direction of the
axis which separates the body into two halves, and never in a natural state
leans more towards the right than towards the left. The bladder then
stretched between the urethra and the urachus inclines neither from above
downwards, nor from below upwards, nor from right to left. The errors on
this subject may ahme have been caused by its connection with the rectum.
In fact the defecator organ does push it more sometimes in one direction
than in the other, whence it happens that it appears more dilated, wider,
more inclined in short in that direction in which it is least-frequentiy and
least powerfully depressed. Now, as the rectum is generally to the left before
it engages beneath the prostate, it clearly appears why the body of the bladder,
naturally in relation with this part of the digestive tube, should seem to lean
a little from left to right in a line from the urachus to the prostate.
From these remarks it follows that as it respects the position of the reservoir
of urine, perineal operations for stone may indifferently be excuted on either
the right or left sides ; and that in the other niethods an incision along the
median line of the body is sure to discover its vertical axis.
The peritoneum, by which the bladder is partiallv enveloped, deserves here
99
786 NEW ELEMENTS OP
our most serious consideration. After having covered its entire posterior
region, and its summit (which is its fundus when distended), it separates from it
on a level with the upper strait to spread over the hypogastric portion of the
parietes of the abdomen. During its distension, as it fills the bladder crowds
back this membrane gradually, so as to leave it at a distance of an inch, or
even two inches from the upper edge of the pubis; hence its adhesions at
this spot are very feeble. The peritoneum is separated from the symphysis
pubis, in the hypogastric region, by an interval so much the larger as it is
examined nearer to the neck of the bladder; which interval is filled by an
extremely distensible lamellar cellular tissue, which is habitually much loaded
with fat. This tissue which is no other than a portion of the general fascia
propria, presents about the same character as it does in the fossa iliaca and
behind the attached edges of all the folds of the mesentery.
In most subjects, it terminates in giving strong adhesions to the peritoneum ;
particularly as we approach the junction of the two upper thirds with the
lower third of the space which divides the pubis from the umbilicus. These
adhesions more speedily contract outwardly toward the iliac regions than
upon the median line. Thus the anterior face of the bladder is separated from
the symphysis pubis merely by the lamellar adipose tissue of which I have
just spoken. This pouch, when it rises above the upper strait is at once in
contact with the posterior surfaces of the recto muscles, or of their aponeurosis,
without any interposition of the peritoneum; and it is consequently possible
to open into it through this spot, without cutting its serous covering. Be it
observed, that between the symphysis and it there are neither arteries nor
veins, nor other important parts to be avoided ; but let it be remarked also
that the slightest traction or effort is sufficient to detach it, and thus to create
a cavity more or less wide and deep between the bladder and outline of the
pelvis.
JTie Walls of the Belly consist in the region now under consideration, of
parts which it is easy to remember. The skin here is covered with hairs, is
not very movable, and of considerable density, especially at its lower part,
at which it would be difficult to follow Middleton's advice, of pinching it up
into a fold before cutting it. The cellular layer here becomes a fatty puni-
cuius or membrane which often acquires a thickness of an inch or more. In
it we find sometimes veins of some size, and some twigs from the cutaneous
arteries, and from the superior pudica externa. The aponeurosis from the
external oblique, joined to the anterior lamina of the internal oblique, ter-
minates in it, as in the remainder of its extent upon the linea alba.
The muscles which are found here are the pyramidales, the terminations of
the sterno-pubic, and much more outwardly a slender portion of the abdominal
oblique muscles, which are not at present to engage our attention. The recti
muscles which are divided from each other by the linea alba are in more than
one respect remarkable. Their tendon growing more flat contracts more and
more, is much thinner outwardly than within, in such a way as that as it
comes to be inserted upon the edges of the ossa-pubis near the skin, it leaves
a portion of these bones uncovered behind, and inwardly projecting. The
outer edge of this tendon being very thin, and continuous with the aponeurosis
oblique muscles, the parietes of the abdomen are infinitely less thick at a
distance of two inches outwards from the symphysis than on a level even
OPERATIVE SURGERY. 78"
with the recti muscles, and it has been thought possible to arrive at the
bladder, by penetrating them just at this spot. Their posterior surface is
covered by a layer of adherent cellular tissue to a certain point analagous to
the deeper lamellas of the fascia-superficial is in general. On the median line
they are divided from each other by a fissure which deepens more and more
in proportion as we descend towards the strait. When it has reached the
pubis, the fissure becomes a triangle whose base is downwards, in which exists
abundance of cellular tissue and fatty flakes, such as were spoken of a sKort
time previously.
The epigastric artery, the only important vessel which is observed in the
thickness of the layers, reaches the edge of the recti muscles to penetrate the
fibres on a level with a line drawn transversely from one external superior
spine of the ileum to the other. As it gives off no branch of any size which
goes towards the median line, we need not fear to wound it in cutting through
the hypogastrium, unless that in the desire to penetrate into the little aponeu-
rotic space, which is bounded within by the tendon of the rectus muscle,
below by the ligament of Fallopius, and outwardly by an imaginary line
which the artery would represent, the incision had been made a good deal too
much towards the fossa-ilraca.
The spermatic cord passing in an opposite direction and lying at a still
greater distance is equally shielded from danger. In going regularly through
the different layers of the wall of the abdomen, we shall encounter beneath
the common integuments upon the median line, 1st, the cellulo-adipose
cushion ; 2d, the linea alba, three or four lines thick, the pubio-vesical triangle ;
Sd, the cellular tissue, which in this region is very abundant ; 4th, the anterior
surface of the bladder.
A little to one side we meet with, 1st, the very thick external aponeurosis;
2d, the pyramidalis muscles ; 3d, a thinner fibrous layer separating these
muscles from the recti; 4th, these last named muscular masses, sheathed
behind by a very thin fascia ; 5th, the fascia-propria, or lamellar tissue as above
described. More outwardly still, the united aponeurosis of the three wide
muscles of the abdomen alone offer for division before we come to the sub-
peritoneal cellular tissue.
The arrangement of the pubis is another point which tlie operator must ever
bear in mind. At the symphysis, they are in general not more than an inch
and a half or two inches high ; so that unless they be extremely short, the
anterior surface of the reservoir of urine may easily be brought to their upper
edge. The convexity of the form of the ossa-pubis from above downwards
is the reason, consequently, why it is easy to make a stone slip in a contrary
direction from the bladder outwards, and why it is advantageously employed
as a fulcrum for lithotomic instruments, and why the wall of the bladder
may without difficulty be cut as far as their lower edge, that is, from the
cervix vesicse or to the prostate. Their body increasing in thickness,
becoming larger and larger as we retreat from the median line, it results
contrary to what M. Drivon asserts, that the bladder is furtlier from the
integuments as we approach the fossa-iliaca of either side, and that if the
converse can be admitted, we should act upon the sort of vacuum apparently
|. created by the vesico-pubal triangle. Sex and age induce some changes of
structure in the arrangement of parts which we have now described. In the
^88
NEW ELEMENTS OF
female the symphysis being shorter, and the bladder naturally raised up by
the vagina and matrix, it is usually higher above the pubis than in the male.
It happens besides, as a consequence of frequent deliveries, that it enlarges
transversely, so as that almost it may be said it divider into lateral portions,
and that it might be opened on the side with less danger than in the other
sex. To these shades of difference has been attributed the greater success
obtained in women from this operation than in men. In youth the narrow-
ness of the pelvis, the lowness of the symphysis, the smallness of curve in the
sacrum, the relatively great bulk of the rectum, the considerable length of the
bladder conspire to raise this latter organ very high above the superior strait
generally, and so its anterior face may be widely opened into, without any
danger of dividing the serous membrane. It will be conceded nevertheless,
that numerous anomalies and changes of a pathological character may alter
these particulars, and invalidate the justness of the assertion which I have
now made.
§ 2. Examination of the Methods of Performing it.
Fewer procedures have offered for the high apparatus than for perineal
cutting, and the methods which belong to it can only be regarded as modifi-
cations of each other. I shall consider them under three principal heads
to analyze them more in order; 1st, that mode in which you operate with-
out a staff being previously introduced ; 2d, that in which the very reverse
is done; 3d, that which differs from either, in having an accessory opening
made beneath the pubis.
1. The Method of Roussct. — The first plan laid down for performing hypo-
gastric cutting, is that which Rousset has described. He began by injecting
barley water, tepid water, milk, or some vulnerary decoction into the blad-
der, so that by its distension it might rise above the pubis. The penis of tlie
])atient was either tied or held by an assistant, to prevent the fluid from flow-
ing out against the wish of the operator. With a good razor the integu-
ments and aponeurosis upon the median line were divided. A slightly con-
cave bistoury was then carried obliquely downwards and backwards, between
the symphysis pubis and the bliidder, the back of the blade towards the bone,
so as to open this pouch with the utmost care. If the opening were very
large, the bladder would at once be evacuated : it must be merely sufficient
to allow of the introduction of a lenticular bistoury, which immediately
enlarges the incision from below upwards, not going far enou2,h however to
reach the peritoneum. Then the stone was withdrawn with the fingers
alone, or artificially armed with stalls, with a scoop, or with forceps.
a. Douglas modified the procedure of Rousset in two points of view. The
organ must be very moderately distended by the injection, according to him
not to paralyze its fibres, and because its extreme distension is often quite
insupportable. For the razor he substitutes a convex bistoury. The straight
bistoury, which he employs instead of a curved bistoury, serves, both for
nuiking the puncture into the bladder, and for at once enlarging the wound
instead of resorting to the probe-pointed bistoury.
b. Cheselden, who likewise does not approve of much distension, advises
the patient as much as possible to retain his urine, and to throw in a quantity
OPERATIVE SURGERY. 789
of liquid equal only to what they would naturally have voided. When he
has laid bare the aponeurosis with a convex bistoury, and divided the linea
alba with a straight one, he takes a sharp pointed concave bistoury, to open
the bladder from above downwards, and not from below upwards, as Rousset
and Douglas had advised.
The curved scissors whicli McGill has recommended instead of the straight
bistoury in this latter stage of the (Tperation, expose the peritoneum too much
to injury to be ever adopted, and in all respects are of so little importance
or advantage as not to entitle the method to an analysis.
c. Morand so alters the procedure of Rousset, that he placed his patient
differently, his head and chest lower than his pelvis, and the legs fixed to
the bed posts. He plausibly insists on the dangers of forcing injection to
any extent, and endeavors to demonstrate its inutility. He is content with
the common straight bistoury for the incision of the parietes of the abdomen,
and the concave one for that into the bladder. He appears to have origi-
nated the idea of using the left forefinger, curved as a hook, to keep the blad-
der at the upper angle of the wound, whilst its dimension is being completed
as Heister had done before him.
d. Others, particularly Le Dran, thought that the peritoneum would run
infinitely less risk of being wounded if it were cut into crosswise instead of
being divided from above downwards. Winslow asserted, that the necessity
for injecting it, might be done away with, by making the patient drink freely
of a diluent tisana for some weeks before he underwent the operation;
and he told Morand that the position adopted by him was ill-suited to
the end. If we rightly comprehend him, it appears that Thibaut, of the
Hotel Dieu, had an idea of returning to the incision from above down-
wards, and like La Peyronie, was of opinion that the bistoury should be so
passed into the bladder at one stroke, as on withdrawing it to divide all the
tissues.
Lecat followed this advice in operating on two patients by the high appa-
ratus, in 1742 and 1743. His cystotome bistoury, whichhe plunged in as if by
puncture, served him for dividing the bladder upwards, then for a moment to
keep it suspended by means of a projection on its convex edge, suddenly
turned in this direction, until he had replaced it by a suspensor hook.
e. Of late years the procedure of Rousset has been subjected to fresh modi-
fications. M. Baudens, a young surgeon from the military hospitals says,
that he has found it a good plan not to introduce any fluid into the bladder;
to open this pouch, as Pietre, Solingen, &c. had advised, a little on one
side ; to carry the left forefinger down to the posterior face of the pubis,
to push the peritoneum up from below, and make it and the bladder tense;
to pass in the bistoury to its cavity from above downwards; to employ his
finger as did Morand, and so continue the incision in the same direction with-
out removing it, as far as the neck of the bladder. Moreover, M. Baudens
thinks that when the removal of the calculus is attended with some difficulty,
we should divide the rectus muscle laterally, and also the lips of the wound
in the bladder, as had before been recommended by McGill and Le Dran.
. f. A particular instrument of an extremely ingenious construction was con-
trived by M. Tanchou to facilitate this procedure. It is a sort of flat trocar,
the sheath grooved on one edge, articulated at some distance from its extre-
790 NEW ELEMENTS OF ^
miiy, and made into a bistoury by a stem with a cutting edge. The opera-
tion is performed in the following waj. The operator makes his incision on
the median line down to the forepart of the peritoneum with a convex bis-
toury. By the assistance of the left forefinger carried to the bottom of the
wound, he detects the fluctuation of the bladder, which he has previously
moderately distended by an injection of tepid water; he then passes in his
trocar, from above downwards and before backwards, draws out the cutting
edge by means of a spring ; the sheath tEen bends at a right angle, and forms
a sus'pensor hook which is developed within, and on the lower edge of which
a common probe-pointed bistoury is conveyed in to enlarge the wound as
much as may he requisite.
g. Lastly, M. Verniere, conceived that an advantageous change might be
made in practising this operation by the performance of a previous one, con-
sisting in incision of the wall of the hypogastrium, and then in placing
between it and the front of the bladder a flat surface {plaque), intended to
compress from behind forwards the peritoneum against the inner surface of
the recto muscles for some days. The adhesions following the pressure thus
made, will, he says, allow of our opening the bladder with every security, and
without the slightest danger of entering the cavity of the abdomen. An idea
analogous to that of M. Verniere, has just been communicated to me by M.
Vidal (of Cassis). This surgeon proposes to perform the operation at two
separate times, between each of which he allows an interval of several days.
The first stage consists in an incision of the tissues which are external to the
bladder, and the object is to render the cellular tissue impermeable by infla-
ming it. The second contains the opening into the bladder, which according
to the author is thus exempt from the dangers of urinous infiltration.
Of all these modifications, no one in reality is worthy of a decided pre-
ference over the others. I think the wisest of them, as far as concerns the
operation properly so called, is that of Morand. To advise the patient to retain
his urine so as to have the bladder distended, is counsel which it is easier to
give than for the patient to follow. To be convinced of this, it need only be
recollected how very often calculous patients are compelled to pass their
water. Injections, carried to such an extent as to render the bladder salient
above the symphysis, cannot in reality be endured : but in the majority of
cases we experience no difiiculty in distending it moderately by the intro-
duction of some emollient liquor, which will suflice to indicate its presence
easily recognizable behind the pubis, by the finger introduced through the
wound in the linea alba. As to the nature of the fluid to be injected, milk,
which Middleton seems to prefer, is evidently less suited by its tendency to
decomposition than mallow infusion, barley water, or better still a certain
quantity of tepid water only. Air, the suggestion of which is attributed to
Solingen, although spoken of by Rousset, who says that in his time they
were advised to fill tliebladder with wind, could have no advantage whatever
over a fluid, and deserves the neglect which it has received. Equal justice
has long been done to the precept of Bamber, that the injection is to be made
only after the opening of the linea alba, and to that of Middleton, who thinks
that it should at least, then be pushed a little further than was done before
the operation commenced.
An incision from below upwards with a straight bistoury, as in Douglas's
OPERATIVE SURe»RY. 791
procedure, or with Rousset's probe-pointed bistoury, would in truth allow of
much certainty in acting by taking the pubis for a fulcrum ; but undoubtedly
we are by this method too much exposed from the instrument's going further
than we wish to perforate the peritoneum, or as Cheselden says, to open the
belly. If we adopt the incision from above downwards, it is indifferent whe-
ther it be completed with scissors, a probe-pointed bistoury, straight or curved,
or with the common straight one, if it be done with a steady hand. A trans-
verse incision of the bladder would, as Winslow has remarked, have the
inconvenience of presenting a wound perpendicular to the direction of outer
incision, which in retracting behind the bone would be singularly liable to
cause urinal infiltration. Moreover, it is very certain that to divide laterally
the recto muscles as was done by Pye, at another time by M. Dupuytren, and
which in our time Gehler washed to establish as a rule, is suitable only in
particular cases, such as when spasmodic contraction, sufficiently violent to
prevent the introduction of forceps or fingers through the wound into the
bladder, occurs, as I once witnessed in a patient upon whom M. Roux operated
in 1827 at La Charite. M. Baudens's procedure, notwithstanding its wonderful
apparent simplicity, has the serious drawback of causing too much tearing of
cellular tissue in detaching the peritoneum. There can be no doubt that in a
case in which the bladder was concealed quite in the bottom of the pelvis, the
absence of injection into it would render the operation extremely difficult.
The mere announcement of M. Veniere's idea, will suffice I fancy to give
all an opportunity to appreciate its worth. That of M. Vidal is more simple
and more reasonable. The wisdom of M. Tanchou's contrivance cannot be
disputed; simply, as it requires a particular instrument having no other
advantage than serving to carry a hook into the bladder, at the same time
that it is entered by puncture, and that the puncture of this sac by a bistoury
admits the finger or some suspensory instrument to be introduced, I presume
that the use of it will be neglected by surgeons, and that good surgery can dis-
pense with it. Some old surgeons, however, had previously felt the want of
it, for Heister advises the puncture of the bladder by a trocar, grooved so as
to serve as a director to a bistoury afterwards.
2. The Method of Franco. — Dionis and Toilet, who have treated of the
high apparatus, think that the surgeon might follow the advice of Franco,
whose method was to carry two fingers into the rectum to raise the stone up
to the hypogastrium, and then to cut down upon it a little to one side of the
linea alba. They are of opinion that this is a very easy and simple method, and
much more certain than that of which Rousset speaks. If the stone is small and
the pubis sufficiently low, and the parts altogether thin enough to allow the
fingers thus to push the foreign body up above the pubis, this procedure would
be verj advantageous and deserve adoption. Proby put it in operation, and
by means of it Lassus and M. de Guise succeeded in removing stones from
the bladder, which through the perineum they could not extract. In fact,
this is nothing but the apparatus-minor of the ancients, applied to cutting by
the hypogastrium, with this difference, that it is easier to cut down to the
stone above the pubis, than when it has to be extracted from the inferior
strait. It is useless altogether to give the steps of the operation in detail.
Franco merely says, that his patient was operated on " upon the pubis, a
792 ^'E^v elements o^
little to one side and upon the stone, whilst he raised this up with his iingei-s
which were in the fundament on the other side, confining it by the hands of
a servant who pressed upon the lower belly." It is well to remark, en pas-
sunt, that Franco had not previously, as a number of books relate, and as is
stated in the Dictionary of Practical Surgery, cut into the perineum of
the child of two years old of whom he speaks — and that it was only after he
had seen every effort unsuccessful in bringing down the stone that he resorted
to *' cutting the said child above the os pubis."
3. 3Icthod of Frere Come. — In the successive improvements which were
inade in perineal lithotomy the hypogastric operation seems to have followed
every change. For a long while it was thought necessary to make the
stone descend towards the neck of the bladder to cut the parts over it; the
same was the case in the high apparatus. The plan of distending the bladder
with injection was a precaution soon adopted in it. Bamber, Cheselden, and
Foubert, in the last century, imagined the same thing in perineal cutting so as
to dispense with the staff. And since this instrument is believed to be indis-
pensable now in all species of the low apparatus, a host of authors have like-
wise advised its use in the super-pubic method. Rousset mentions without
advocating it. It seems, that in his time it was a hollow and crested staff
which w^as at once a catheter through which to throw in injections if thought
advisable, and as a '* catheter to direct the incision after the manner of the
Marianists ;" which means, no doubt, that the convexity or groove was turned
forwards, not a very easy thing to do. Still later the staff was advised by
Pietre and Heister, &c. ; by some to distend and raise the bladder ; while
others had caused its concavity to be grooved, in a manner proper for carry-
ing the point of the bistoury along it.
The instrument which has in this respect excited most attention, is that
invented by brother Come about the middle of the last century," and which
gave the monk so great a predilection for the high apparatus, that between the
years 1758 and 1779, he had performed it one hundred times. This instru-
ment, known by the, name of "sonde a dard,^^ consists of, 1st, a silver
catheter, opening by a fissure on its concave side, ending in a beak which
rather projects backwards, and has one or two rings at its oute^ end ; 2d, of
a stem much longer, which ends in a triangular steel point, also grooved on
its concave side, and which has a flat blunt knob on its other extremity.
These two portions, the last of which is always kept within the other in such
a way as to escape as soon as pressure is made on the button or knob of its
free extremity, form an instrument whose mechanism is exceedingly simple.
It is introduced in such a way as that its beak may glide from below upwards
behind the symphysis, and rise up above the pubis, passing against the inner
side of the anterior region of the bladder. The abdominal parietes being
divided, its point or beak is made to bulge up a little into the wound by
pressing on the top of the handle as if to push it backwards, and so as to
depress it. The surgeon takes hold of it through the coats of the bladder
by its projecting part with his thumb and forefinger; or else he applies upon
its fore part a canula hollowed out and shaped like a funnel. The knob then
being pushed fi'om below upwards perforates the bladder as it escapes from
the '* sowrfe," and shows itself outwardl}^ Whetlier this knob unscrews from
the stem so as to leave the latter in the wound, or whether they be in one
OPERATIVE SURGERY. 793
•
piece, the bistoury is adapted to the groove in its concavity, then passed from
above downwards, and from before backwards to cut the wall of the bladder
to a suitable extent. Nothing then remains but to withdraw the stylet, whose
projecting beak has not yet quitted the wound, back into its sheath, and then
to take out the instrument itself. The other stage of the procedure does not
differ from that of Morand's.
The sonde a dard thus completely does away with the necessity of injec-
tions, for it makes the parts suitably tense ; and its grooved stem makes an
excellent director when the opening into the bladder is to be enlarged with
the bistoury. Scarpa and M. Belmas have proposed certain modifications in
it, with the view of rendering its use yet more efficient. For example, it is
often objected to as escaping entirely through the puncture it has made, and
as allowing the bladder to contract before it was possible to finish the open-
ing into it with the bistoury. The surgeon of Pavia thus obviated that defect.
His catheter was only grooved to within a few lines of the end which forms
its beak, which is olive shaped. The groove moreover is very large, and
strongly excavated so as to leave a furrow on either side of the stylet, deep
enough to slide the beak of a bistoury along. The piercing stem destined to
pass through it, quits it by degrees, and passes out two or three lines below
the head, which thus remains in the bladder and cannot escape in following
the stylet. Scarpa says, besides, that its edges can always be felt through
the bladder with the nail, and that the bistoury passing on one side of the
dard, may be carried into it without danger.
The sonde of M. Belmas is also a very ingenious contrivance, but is so
very complicated, that what it has fundamental about, will not be adopted.
Other directors have besides been proposed at different periods. Cleland,
for instance, contrived a sound in the last century, which bifurcated like
forceps when introduced into the bladder, and thus rendered the walls of
the organ more or less tense. Kulm and Heritier, &c. produced nothing
better, and the very complex apparatus which within a few years M. Rouget
endeavored to bring into use, the object of which was to pierce at one stroke
the entire thickness of the bladder and abdominal pai'ietes, is no longer
worthy of being mentioned.
The question is, to know whether the only object in the directing instru-
ment shall be to make the organ tense and prevent its -collapsing, or else,
whether it shall at the same time puncture the reservoir from within outwards,
so as to furnish a more certain guide to the bistoury which is to complete the
incision.
If the first of these ends is proposed, a.common catheter will answer all
the surgeon's expectations ; if the second, the sonde a dard, the original or
that modified by Scarpa, leaves us in truth nothing to desire.
The use of directors, however, is not the only change which has been made
in performing hypogastric cutting. Several surgeons have advised that an
additional incision should be made beneath the pubis. This process had
been performed by Sermes, a dutch surgeon, who was on account of it pro-
secuted by the law and defamed by envy; it was then reduced to simple
puncture, and then in some measure assimulated to lateralized cutting.
Sermes recommended it as a means of introducing the suspensor sound.
Pallucci punctured the same part with a trocar, and leftacanula in the wound.
100
794 NEW ELEMENTS OF
Deschamps thought that the puncture should be made through the rectum, so
that the instrument, armed with its dart, might pass in. After all it is to
brother Come that this supplementary incision owes all the popularity which
it once enjoyed. This lithotomist, who commenced his operation with it,
cut the membranous and partly the prostatic portion of the urethra upon a
grooved staff, and then used this wound to pass his sonde a dard into the
bladder. After the operation, a thick and short canula was left in the wound,
which by giving vent to the urine was to prevent it from rising up into the
hypogastrium. The arguments and success of F. Come for a while deceived
the profession as to the value of this incision; but very soon men began to
ask themselves if the high apparatus really derived any advantages from
this incision, or whether it was not the cause of a dangerous complication.
It was easy to prove, 1st, that a wound in perineo in nowise prevented
the urine from rising into the wound in the epigastrium; 2d, that it was
not indispensable for introducing the sonde a dard; and 3d, that it must
combine all the dangers of perineal cutting with those of the hypogastric
method also. So, Scarpa in 1808, and Dupuytren in 1812, endeavored to
suppress the modification of F. Come, and to demonstrate that it was quite as
easy to operate with the instrument invented by the latter, when carried into
the bladder through the urethra as when introduced by the perineum. The
routine of the Feuillant monk* continued to be adopted, when Mr. Home de-
parting from the track twice performed hypogastric cutting in 1819 and 1820
upon the principles laid down in the essay of M. Dupuytren. Some years
after, M. Souberbielle himself abandoned the precepts of his grandfather,
which he has never followed since 1825; so that this is now a settled ques-
tion upon which it is no longer necessary to dwell.
§ 3. The Method of Operation,
Notwithstanding their points of difference, the procedures which have now
passed us in review possess features which are common to them all. These
rules relate either to the position of the patient or to the incision of the
tissues, or to the means of carrying off the urine, and of dressing the wound
after the operation.
1 . Position of the Patient, — It should be similar to that recommended in
the operation for hernia, with this distinction however, that it is proper to
raise the pelvis a little. If the legs are allowed to hang over the table or the
bed they will put the abdominal muscles very much upon the stretch and
cause several inconveniences in this way. Flexion of them, as in parietal
lithotomy, would interfere with the motions of the operator. The operation
might in fact be done on a bed ; but a na,rrow table, of proper height, makes
the position of every patient infinitely more convenient.
Injection, Placing the Conductor. — When we mean to follow the plan of
injecting the bladder and eflect its distention by means of liquids, we must
begin by introducing a common catheter into the urethra. To the open
end of this, the pipe of a syringe filled with warm water is then fixed.
The process of injection is very slow, so as to pour into the bladder as
much fluid only as the patient can bear without feeling too much pain. At
* A friat of the reformation of St. Barnard. — TnAifs.
OPERATIVE SURGERY. 795
the present day no one would think of using the ureter of an ox, the trachea
of a turkey, or a copper staff, as advised by Douglas, Cheselden, Mid-
dleton and Solingen, to connect the syringe with the catheter, so as to avoid
all kinds of motion or shaking. The injection being finished, an assistant is
immediately requested to compress the urethra, to prevent the fluid from
escaping too soon. Many patients it is true, do not require this caution ; but
as this is not the case with some others, prudence forbids our dispensing with
it. The fingers are much better than any of the compressors invented by
Nuck, Winslow, and others.
Incision through the external parts. — The surgeon proceeds to open the
wall of the hypogastrium, standing on the right side of the patient, rather
than between his legs, as M. Belmas recommends. It would be childish to
argue about the superior advantages of this over the other bistoury at this
period of the operation. It matters little whether it be a razor, a straight or
a convex bistoury, or a small knife, so that it be only very sharp ; except, that
as in the sequel the straight bistoury is the most convenient, I think that as a
general rule it deserves the preference. You hold it in tlie first position, i. e.
like a table knife ; and after having stretched tlie parts with the left hand, you
divide the parts from above downwards, for a length of at least three or four
inches, 1st, the integuments, 2d, the adipose cellular layer, and so come down
to the aponeurosis. Whatever Zang may say this incision had better be long
than short, and though contrary to the advice of Winslow there is an ad-
vantage in carrying it down on the fore part of the symphysis for half an inch
below the upper edge of the pubis.
All surgeons do not perform the division of tlie aponeurosis in the same
way. Some do it with the instrument they have all along used ; others, among
whom is Scarpa, prefer that, after having cut it completely down, a director
should be passed beneath it, which may insinuate itself between the peritoneum
and the abdominal wall from below upwards, so that on it a bistoury may be
directed in the like direction to cut the entire thickness of the fasciae.
For this purpose F. Come employed an instrument which ended by a trian-
gular point on one side, by a handle cut in facets on the other side, enclosing
a cutting blade which has a flat plate at its free extremity, and which opens from
haft to point, consequently in an opposite dirfiction to the sheathed lithotome.
This trocar is plunged from before backwards, and from above downwards,
until it gets between the symphysis and anterior wall of the bladder. The
surgeon then with his right hand fixes the stem against the bone ; seizes the
flat plate with the thumb and forefinger of the left hand; carries this plate
from the handle from below upwards, and divides in the same direction the
linea alba and other tissues with which the blade meets in its passage. Having
withdrawn the trocar, F. Come substitutes in its place a bistoury ending in an
olive-shaped point, solid in the handle and cutting on its concavity; cuts from
below upwards, holding this second instrument in his right hand directed
by the fingers of the left hand, all the laminae which may at first have
escaped, and takes care to pass the knob into the bladder, the peritoneum,
and even the deep surface of the aponeuroses.
At first sight the method of F. Comeseemsmoredangerous than any other.
It is terrifying to see his trocar-bistoury acting from below upwards and from
before backwards, without any guide to control its direction. However as it
796 NEW ELEMENTS OF
cuts rather bj pressing than bj sawing, and as its blade when open as far as
possible represents a line drawn very obliquely from the integuments to the
bladder, it is rare for the peritoneum to be really injured. The only rea-
sonable objection which can be raised against it is that it is not indispensable,
and that a person accustomed to perform the great operations in surgery will
do it just as surely with a common bistoury. With this view, I do not
consider the improvement made in the instrument by M. Belmas as of any
great value ; it consists in making it concave on the back and convex on the
cutting edge. As to the probe-pointed bistoury of the inventor, I have, I
dare say a thousand times substituted the common probe-pointed bistoury for
it in the hands of pupils operating upon the dead body, and never yet felt the
want of an instrument specially for the purpose. Almost all surgeons at the
present day, advise us to cut directly down upon the median line; however,
returning to the recommendations of certain authors, M. Baudens has recently
exerted himself to prove that it is better to cut outside of this fibrous line,
because the wound, if made between it and the inner edge of the rectus
muscle, will be less difficult to enlarge and it will be more easy to part its lips
to come upon tlie fore part of the bladder. This is a piece of advice again
which may be followed or neglected without any unpleasant result. The
thing needful is to get between the two sterno- pubic muscles, and not to go
across their fibres. After this, whether the linea alba remain untouched on
one side, or be actually split into two equal parts, need cause us no uneasiness.
Besides which it is generally so difficult to detect it beneath the adipose tissue,
that the knife is guided almost constantly by data approximating to that direc-
tion in wliich it usually exists. I may add that if it is better notto go through
fleshy fibres, it is not from any fear of incising them, but because of the
greater depth to be gone through before we come to the sub-peritoneal cellular
tissue, and because also, the serous membrane is found more closely applied to
the thick wall of the hypogastrium outside of and not upon the median line.
The straight bistoury of the common kind, held like a table knife or like a
writing pen, is as good as any other to divide the skin, fatty layer and apo-
neurosis from above downwards and alternately.
When the surgeon comes to this aponeurosis he must proceed with great
slowness, and divide it layer by»layer, pressing more strongly upon the part
nearest the pubis than upon the upper end of the wound. As we always
come upon the pubio-vesical triangle on the median line, and with a little
attention we may always tell when we have reached it, the peritoneum" runs
in truth no risk at this part of the operation. Supposing that very close ad-
hesions superiorly should prevent us from opening the aponeurosis sufficiently
deep in this direction, we must then take a probe-pointed instead of a straight
bistoury. Its point is to be carried into the triangle just indicated above
the pubis, against which the operator may for greater security rest the back
of the knife with his right hand ; the left thumb and forefinger take hold of
the blade by its sides to pass it from below upwards, and make its probe point
slide over the anterior surface of the bladder, or the inferior portion of the
peritoneum itself, for an extent of about two inches between these parts and
the deep surface of the linea alba.
It is very true that the bladder maybe opened with less danger below than
higher up, but in the first case the cutting edge of the bistoury must be
OPERATIVE SURGERY. 797
turned towards the umbilicus, bj which the peritoneum is considerably en-
dangered ; whilst in the other we are pretty sure to avoid it altogether if it is
not injured at starting.
The idea which Middleton and some others had of looking for the urachus
or.the central spot which separates this ligament from the pubis, is a useless
one. The important point, and the only one, is to come upon the anterior wall
of the bladder at a spot not covered by peritoneum. This is to be punctured
with the straight bistoury, or with the small concave knife of Cheselden, or
Rousset, carried along the nail of the left forefinger and inclined from above
downwards. As it is withdrawn care must be taken rapidly to enlarge the
wound, so as to introduce some suspensory instrument immediately into the
bladder. The index finger crooked upwards like a hook, will at first do in-
stead of it. If afterwards the walls of the abdomen seem very thick, and
make it difficult to get down to the urinary bladder, we may adopt Zang's advice
and pull the edges asunder by means of small blunt hooks. The curved fin-
ger serves anew to direct the bistoury made use of to enlarge the wound in the
bladder, and extend it towards the neck for an inch or more according to the
supposed volume of the stone. In common cases the same bistoury, that is,
the straight bistoury, is here also sufficient, and is even better than a probe-
pointed one, inasmuch as that its point when being withdrawn better divides
the tissues. If the embonpoint of the person should make it difficult to em-
ploy it, it might well be superseded by Pott's concave bistoury, which
would do away altogether with the concave instrument contrived by
tlie ancients. As to curved edged scissors, I know of no circumstances in
which they can deserve a preference. If the finger takes up too much room
at the time of introducing the forceps, or of the extraction of the stone ; if we
are afraid of getting it injured during this latter manipulation, as Deschamps
instances an example, whether it belong to the surgeon or the assistant it had
better be removed and a proper instrument substituted for it. The blunt hook of
F. Come is perfectly proper ; but the sort of gorget with a handle bent at
nearly a right angle near the end, which was constructed by M. Belmas, would
evidently do better. Indeed this suspensor, the groove of which should look
downwards, would keep open the lips of the wound whilst it constituted an
excellent director, without giving any inconvenience whatever to the inner
surface of the bladder or the artificial opening. Nothing now remains but to
extract the stone. But before I proceed to this step in the operation, I shall
stop to consider those necessary when the sonde a danl is used instead of
injections.
Use of the Director. — When a director is employed, it had better be intro-
duced before the hypogastrium is opened than afterwards ; Jirst, because its
beak will then serve as a guide in some cases above the pubi?; and secondly,
because the patient will suffer more from its subsequent introduction. I
suppose now that it is the sonde a dard, which we are to employ. It is intro-
duced like a common staff, its concavity pushed behind the pubis, and thus its
point is tilted up above the superior strait opposite the linea alba. An
assistant is directed to hold it in this position, whilst the operator proceeds to
divide the integuments and aponeurosis. When the bladder is laid bare, the
latter takes the sonde into his own hands again, withdraws it a little to raise
its beak from below upwards, rubbing gently against the pubis in such a way
798 NEW ELEMENTS OF
as that the peritoneum may not intervene and form a fold before that point in
the wall of the bladder through which the point is to pierce to pass into the
wound. The left forefinger passed down to the bottom of the incision, follows
its motions, and indicates the degree of elevation and protrusion to M'hich the
instrument has attained. Having suitably fixed its position, it is again given
to the assistant. The surgeon pinching the sides of its salient extremity then
desires the assistant to push out the dard, which passes to a length of from
one to several inches; he then, if he fears that it may inconvenience him,
unscrews its point. Without displacing the left hand, in the right he takes a
bistoury, which according to Scarpa should be convex, but according to Belmas
just the reverse, and which however does equally well whether it be the
common or the straight ; the point of this held like a pen he places in the groove
of the dard ; passes it along into the bladder, and divides this organ upon the
median line from above down, and from before backwards near the neck or
prostate gland ; draws back the dart into its sheath, and directly introduces
his left forefinger into the bladder. The assistant removes the instrument.
If the surgeon thinks it necessary to use some artificial suspensor, he sets
about the introduction of that which he selects at once > takes the hook or the
curved gorget, supposing him to choose it, in his right hand ; presents it at the
vesical opening in the most suitable direction ; raises it when it has entered ;
slips it, instead of his finger which he withdraws, into the lower angle of
the wound, and then gives it in charge to his assistant. Both hands being
then free, he can fearlessly explore the inner part of the bladder, and judge
of the situation and form of the calculus which is to be extracted as the
termination of the operation. This may often be done by the curved finger,
the thumb and index finger, or the forefinger and a scoop; in others it de-
mands the use of forceps, which here admit generally of more easy manage-
ment than they do in sub-pubic lithotomy. The precautions to be attended to
in using them are precisely the same, save that more care must now be taken .
than before to avoid detaching the bladder from the pubis and abdominal
parietes, by tearing the lax cellular tissues which connect these parts with one
another.
The Dressing. — Cystotomy above the pubis, different from other varieties
of operation for stone, has much engaged the attention of surgeons as it respects
the dressings which are adapted to it. In the time of Rousset stitching the
wound was practised, and has since often been put in execution. Through its
assistance it was hoped that urine would be prevented from escaping by the
hypogastrium, and causing infiltration outside of the bladder. TJiis suture,
which was oftener recommended than adopted, was not understood in the same
sense by all author? who ventured to advise it. Solingen, one of its warmest
partisans, does not express himself with sufficient clearness for us to under-
stand positively whether he sewed the skin merely, or included in the stitch
all the thickness of the lips of the wound. Others have spoken on the subject
more categorically. Douglas, for example, thinks that the suture through the
integuments will be sufficient. Professor Rossi, on the contrary, maintains
that above all things we must endeavor to sew the wall of the bladder itself,
and Dr. Gehler asserts, that we should include both in one thread.
The question here stated is a serious one, which can be determined only by
experience. Hitherto the cases related, either in favor of or against using
OPERATIVE SURGERY. 799
suture scarcel}' prove any thing. Heister indeed says that Pra3bisch having
performed it upon a patient, the man was soon attacked with such alarming
symptoms that he was obliged to cut the stitch and withdraw the threads.
But how was this done? What tissues had it penetrated? How far was
coaptation perfectly affected ? Of all this we know nothing whatever. Yet
until we do know it, it is impossible to say whether it is to the stitch or the
surgeon that these symptoms which Heister describes are to be attributed.
In the year 1825, M. Pinel Gmndchamp engaged in some researches upon this
subject. He opened and sewed up the bladder in a certain number of dogs,
and in this animal the operation so perfectly succeeded, that in no case did
the least effusion occur, but immediate adhesion followed in all. Since then
M. Amussat has decided in favor of it, and some successful cases have been
related in the Journals which were communicated by him to the academy of
medicine. v
Still it is a method against which numerous and powerful arguments may
be urged. And first it is not probable that any one for the future will resort
to suture of the integuments alone, nor to that of aponeurosis or muscles. It
in fact closes the passage of urine, but does not prevent them from escaping
from the bladder; compelling this fluid, in other words, to effuse itself in the
pelvis. As to suture of the wound in the bladder it is far from being always
easy. Did the urinary bladder remain distended to the close, or did the in-
cision in its anterior wall not go below the upper edge of the symphysis,
and were the hypogastrium always thin, we might indeed, I think, look for
success from it. But since the incision extends towards the prostate, how
can we be sure that we leave no void between its edges in its lowest part ?
And if they are not in perfect coaptation who does not perceive that an oozing
of urine will infallibly occur, which fluid will be effused between the organs
it is intended to close, and more or less solid tissues which surround it.
Lastly, it is also to be apprehended that the stitches themselves by enlarging
will allow passage to the urine, and some regard must be had to the pain which
they occasion and to the length which they give to the time of the operation.
It is a method, therefore, which is of advantage only in cases where it
is possible to coaptate with perfect nicity the incision in the bladder in its
entire extent; but it also demands that the furrier's suture, the only one which
can reasonably be adopted, should be capable of being perfonned without
tearing too much, or disturbing too extensively the circumjacent cellular
tissue. As it is necessary to leave a portion of the thread to hang out of the
wound, which of itself would not fail to prove a cause of abscess and infiltration,
I think upon the whole that in hypogastric cutting, suture in any form ought
to be rejected.
The indication, nevertheless, which the introduction of stitches is intended
to answer, is one of a very important kind ; and has therefore unceasingly
engaged attention. After many trials it was thought that to leave a catheter
in the wound would be a very sure way of carrying off the urine outwardly.
Solingen seems to have been one of the first who conceived this idea. It is
not yet quite certain whether the leather catheter of which he speaks was not
introduced per urethram, and not into the hypogastrium ; but a German sur-
geon, Huermann, leaves no doubt on the subject, for Sprengle distinctly states
that htt much lauded the usefulness of a catheter buried in the incision after
800 NEW ELEMENTS OF
the operation. An operation performed in the month of December 1818, and
published in the following year in Dublin by Mr. Kirby, shows that this
gentleman had confidence in Huermann's practice, for having performed the
nigh apparatus he left a tube in the wound. In France, M. Amussat, who
thought the idea original with himself, expressed himself strongly in its favor.
The tube he uses is two or three inches long, as thick as a finger, and terminates
m the bladder by a swelled extremity perforated with holes like the spout of
a watering pot. When introduced he closes the cut directly above and below,
either by stitches or adhesive straps. Unhappily the hopes by some enter-
tained of this practice have not been realized. Mr. Kirby after four days
perceived the urine passing out between the canula and the edges of the
wound. In some operations performed by M. Amussat himself, the same
thing happened. Afterwards the case of a patient at the Hospital St. Louis,
in whom the tube did not hinder even if it were the cause, the formation of
an urinary abscess. Moreover it is impossible to conceal one's surprise that
M. Amussat should extol such a method, and ascribe such vast advantages to
it, when he confesses himself that he has lost three patients out of twelve;
while more than a century ago Sermes lost only one in sixteen, and Thornhill
two out of thirteen. It is a law of the human organization that an enclosed
foreign bpdy, pressing equally on every side in the centre of a wound, is soon
at liberty, and allows fluids to escape upon its external surface. A canula
therefore cannot prevent urinal infiltration; and as its presence must be
attended with inconvenience it well deserves the neglect in to which it has
fallen. With so much reluctance have surgeons abandoned this idea, that
they have turned their thoughts into another channel in order to eiFect the
object — that of carrying off the urine externally as rapidly as it is furnished
by the ureters.
For this purpose M. Segales has proposed that a skein of cotton should be
enclosed in a gumelastic catheter ; that one end of this skein should be placed
in the bladder, and the other end be left hanging out of the urethra to act as a
filter ; doubtless forgetting that even admitting its efficacy, the thing should
answer exactly the same end though it were placed in the wound in the hypo-
gastrium. M. Souberbielle has recommended the use of a breath syphon,
made of a thick flexible catheter placed in the urethra, and of a long gum-
elastic stem, which is plunged into a vase placed beneath the level on which
the patient lies. To fulfill the same indication, M. Heurteloup has invented
the " uretro-cystic tube," which in a measure combines the plans of MM.
Segales and Amussat, as it is composed of a hollow stem which passes out of
the wound, and a similar one which fills the urethra, so that the urine must
enter by lateral apertures which it meets with near the neck of the bladder,
and of course escape by one end or the other. Experience has not yet
declared in favor of either of these resources : and when we reflect
upon the irritation to which they subject the urethra, the bladder, or the
wound; when it is noticed that in the horizontal posture assumed by the
patient after the operation, the level of the artificial wound is sometimes
lower than that in the urethra opposite the suspensory ligament of the penis,
it is really difticult to coincide with the inventors in the advantages which
they promise themselves. One thing to which enough attention has not been
paid, is the reason of this almost insuperable tendency which the urine has to
OPERATIVE SURGERY. 801
flow over the pubis. It seems, at first glance, that it must ascend contrary to
gravity. But on a closer inspection, this does not appear to be the case. In
fact, it is rare for the vesical incision in hypogastric cutting not to descend
nearly as low as the prostate, and at least to the middle of the height of the
symphysis. This granted, it is easy to assure oneself that the urethra when
it escapes from under the arch rises to as great a heiglit at least, even when a
man stands in an upright position ; and that lying down or in a horizontal
posture, the urine certainly has further to go to get there than to reach the
lower angle of the wound. It is consequently all labor lost which is spent in
the attempt to use similar measures. Most practitioners limit themselves to
the use of skeins of cotton or strips of linen, of which one end rests in the
bladder to act as a filter. Pledgets of lint and dried roots of plants would do
more harm than good. It is not certain that the simple strip of raveled linen,
used by F. Come has any solid advantages. Certainly if it be recurred to it
ought not to be steeped in oil, nor any sort of grease ; and as blood, pus, &c.
wliich it imbibes speedily, before long destroy its permeability, very little
benefit can be expected from it. The only real necessity which the surgeon
feels is to prevent the parts as they approximate too soon towards the integu-
ments from off'ering any impediment to the flow of fluids coming from the
bladder. If, during the first twenty-four hours, we were to put nothing
between the lips of the v/ound, some danger might be apprehended in this
respect; but later than this, when the morbific process has commenced the
perviousness of the tissues is so much lessened that we rely upon the organism
for all that concerns cicatrization and the exit of urine.
The position of the patient after cutting by the high apparatus need not be
continued as long as iii perineal lithotomy. He may turn to one side
and to the other, and even sit ; at the present time no one would advise
that he should lie constantly on Ids abdomen, as was tlie idea of some one in
the last century. I may add, that when the time for the first symptoms to
occur is past, at tlie end of five, six^ or eight days, and no accidents have
happened, and no fever is present, the patient may leave his bed and soon
after walk about without risk, and on the contrary, with advantage; for a ver-
tical posture or a sitting one indisputably favors the passage of urine through
the natural passage.
Unfavorable Occurrences. — Hemorrhage, to prevent which so much care
has been taken in perineal lithotomy, and against which it should seem that
cutting through the hypogastrium must offer security, has notwitlistanding
several times been known to follow this latter operation. Pye has recorded a
remarkable example of it. Another exists among the cases of Thornhill, as
related by Middleton ; a third in the works of M. Belmas ; and I understand
that last year it had nearly proved fatal to a patient operated on by M. Sou-
berbielle. Tims far surgeons have not specified the particular vessel from
which it issues. Some have thought that it depended on the subcutaneous
veins or arteries being larger than usual. Others have supposed arterial
anomalies in the thickness of the linen alba, or in the fascia propria. It has
also been attributed to sano-uineous exhalation from the inner surface of the
bladder. All these are merely more or less probable suppositions; not facts
really demonstrable. Anatomy would soon explain the occurrence if prac-
tice had been more intent on determining its seat. It might so happen, for
101
802 • NEW ELEMENTS OF
example, that the arteries which ascend naturally over the sides of the bladder
and cross one another above its neck, might form a loup large enough to produce
it. It would be equally possible that the dorsal arteries of the penis, coming
directly from the hypogastric and passing on the sides of or above the pros-
tate, as described by Burns, Senn, Shaw, &c. might be divided if the incision
extended very far down.
Be this as it may, the event is an uncommon one, and art possesses several
means of conquering it with facility. If it occurs during the performance of
the operation, all the divided tissues being beneath the eye, it may be possible
to lay bare the open artery, to seize it with forceps of sufficient length, and to
twist or tie it. Under opposite circumstances, that is to say, when hemorr-
hage does not come on until after the dressings are applied, we may begin by
keeping them moist with cold water for several hours, unless the quantity lost
is likely to exhaust the patient. In that case we must remove the dressings,
and look for the vessel. If it can not be got at or its situation be discovered,
tampons soaked in the eau de Rabel, or some other styptic liquid, should be
passed down even within the bladder itself; or we might pass into it a roll
of lint of some size, tied in the middle by a long double thread, capable of
receiving between its two ends a second tampon, on which they should be
fastened in front of the wound in such a way as to compress the tissues suf-
ficiently from behind forwards. We should previously remove all the coagula
contained in the bladder, and wash out this sac freely by injections of water.
Middleton says, that the prostate may be wounded when the incision is too
deep, which is true ; and besides, that this wound often gives rise to a dan-
gerous ulcer, which appears to me to be wholly unfounded. He also speaks
of injury done to the symphysis pubis, and the consequences which may
result; but at this day no one troubles himself about such lesions, which in
fact are not worth being pointed out.
Abscess. — The formation of abscesses round about the bladder is one of the
occurrences most to be apprehended. Douglas, Cheselden, and almost al!
authors who since then have treated of hypogastric cutting, have mentioned
them. There are two orders of them which we must be careful not to confound.
The one depends upon the infiltration of a greater or less quantity of urine
between the bladder and surrounding tissues ; the other is the mere result of
inflammation in the cellular tissue of the pelvis.
It is easy to see that if the operation has been attended with a gootl deal
of detachment and extensive laceration, urine will easily escape into the cel-
lular tissue, instead of escaping externally, and we all know how dangerous
are the inflammations caused by the irritation of urine. When no detach-
ment has occurred, infiltration is very rarely observed. Indeed, after a few
hours, the lips of the wound have lost much of their porousness, and fluid
goes through them without getting into their meshes by weight or capillary
attraction, as might have been feared; so that unless an excavation, a cul-
de-sac allows of its accumulation in it outside of the bladder, it is not com-
mon for its escape through the opening in the hynogastrium to be troublesome
after the first day. Unless the reaction be excessive the parts become very
red; unless tliere be very high fever with a strong full pulse, sanguineous
evacuation, either general or by leeches, is rarely required in such cases.
Urine spreading by transudation into the lamellar tissue, is a death-bearing
OPERATIVE SURGERY. 803
fluid. If there is anything that can stay its ravages, it is only incisions in
large numbers, made deep into all the infiltrated parts and their neighborhood
as soon as possible. Unhappily this means cannot always reach the seat of
the evil ; but of course they must be always performed wherever they can be
made with safety. The wounds are then dressed immediately, at least until
the eliminatory inflammation shows itself, with camphorated brandy, decoc-
tion of kino, or some of the chloruretted solutions. Common abscess, without
urinal infiltration, is less frequent; and depends almost always upon the
manner in which the operation has been performed.
When the bladder has been opened by the dard or bistoury, it is so easy for
the forefinger to push it back instead of entering its cavity, that it often de-
taches it entirely from the back of the pubis ; and creates here a large pouch,
which almost necessarily causes violent phlogosis followed by profuse sup-
puration. I have no doubt that this has happened in most of those cases in
which it has been asserted by operators that the bladder consisted of two
cavities, the one anterior, in which nothing was found, and a posterior one
which contained the calculus. Here an antiphlogistic treatment is necessary
when the patient is able to support it ; and that this serious aft'ection is not
furtiier complicated by urinal infiltration the fluid must be evacuated, as
freely as possible and we must not fear to multiply incisions or to extend
their length in diff*erent directions.
Injury of the Peritoneum, — The injury most spoken of in hypogastric cut-
ting is incontestibly that of the peritoneum. Nearly all authors have con-
sidered it as one of the most alarming, and some as being invariably fatal.
Without wishing to extenuate its danger, I do think that the risk has been
singularly exaggerated nevertheless. Certainly it alone is not very much to
be feared. It is dangerous rather from allowing the urine to pass into the
abdomen. Now the operation is no sooner ended than the bladder collapses,
retracts, and gathers itself into a heap behind the symphysis pubis. The
w^ound in its wall then ceases to coincide with that in its serous tunic. Con-
sequently the urine cannot in truth escape in that way and reach the abdomi-
nal cavity. What proves this much better than argument, is the fact that
the peritoneum has often been wounded without any serious accident result-
ing, and that in those who have died with this injury about them, causes of
death perfectly unconnected with its occurrence have been discovered. One
of Douglas's patients had the peritoneum opened, and yet recovered as well as
if nothing had happened. One of Thornhill's was equally fortunate. It is
even said of another who likewise recovered, that the intestines came through
the wound, and their reduction became necessary. This accident has been
met with by F. Come and M. Souberbielle, who neither of them seem to fear
it. A woman, who was operated on at Tours, in 1828, by M. Crozat, had also
a very large opening in the peritoneum; nevertheless she perfectly recovered.
They say that last year a celebrated operator was not equally lucky; but if
the statement given of the operation is a faithful one, a pledget was intro-
duced into the interor of the serous cavity instead of into the bladder ; and
therefore this case can be considered as no criterion of the danger of cutting
the peritoneum. It would, I think, be adding greatly to its danger when it
does happen to sow its edges, as McGill recommends, or to stitch up the
whole solution of continuity, at least in its upper part, as Douglas advises us
804 NEW ELEMENTS OF
to do. A pledget of lint or a strip of linen placed quite below the cut, pene-
trating even into the bladder is all that in such a case is reallj required. A
strip of diachylon plaster may be put on above, and the patient should be
prohibited from making any motion capable of pusning the viscera towards
the peritoneal aperture.
B. Of Cutting for Stone in the Female,
Women are much less liable to calculous affections than men, and get rid
of them much more easily. The urethra in them is short, straight, and wide,
so that small calculi pass through it with the greatest ease, and seldom grow
to any size within the urethra. However, they are sometimes observed, and
then it becomes necessary to have recourse to the same means which are
employed in the other sex for their extraction. Lithotomy in women is
equally performed by the high and the low apparatus. The first of these
methods, as it is subjected to the same rules in every respect as in man,
requires from us no description ; not so the second, in which we shall perceive
that recto-vesical cutting is superseded by the vagino-veiscal and lateraiized
cutting by incision of the urethra.
Art. 1. — Anatomical Remarks,
The bony strait, which in females is much wider and more shallow, offers
in other respects the same anomalies, the same peculiarities, gives insertion
and attachment to the same muscles and aponeuroses as in the male. The
soft parts alone are not similarly distributed, Thevagina, situated between
the rectum and the bladder, is the cause of most of the differences observed
in it. It is this part, which renders the -^tudy of the posterior aponeurosis
and of the intestine, and likewise of the perineum properly so called, almost
useless, as to whatever concerns lithotomy in the female; which makes the
horizontal aponeurosis almost wanting; and which does away almost with the
free triangular space between the ischio, and bulbo cavernosi muscles, so that
our remarks must be confined wholly, or nearly so, to the urethra, uretro
vaginal septum, and the tissues which immediately connect and surround
tliem. The urethra is from twelve to fifteen lines in length; it is wider back-
wards than in front by a diameter of two to three lines; superiorly it is
slightly concave, and is neither surrounded by prostate gland, bulb, or by a
spongy portion, so that in some manner it is reduced to the membranous
portion of tlie male. Backwards it is adherent in its whole extent along
rhe median line to the wall of the vagina, and corresponds to the longi-
tudinal ridge to the anterior median column of this canal, which interposes
between their interiors a thickness of three or four lines. As the vagina
is much wider, it naturally extends on either side beyond the urethra, and
seems even in certain cases to turn up, laterally, as if to embrace its con-
cavity ; from whence it follows, that a cutting instrument would infallibly
wound it, which should pass from the duct of urine obliquely outwards and
downwards. It is conceivable moreover that this wound would be the more
likely, according to the width of the vulvo uterine canal, and to the number of
labors greater or less had by the woman, consequently greater in the mar-
i
OPERATIVE SURGERY. 805
ried woman than in virgins and children. The bas-fond, or vesical trigonal
space, is like the urethra connected with the anterior face of the vagina ; but
instead of quitting it as in man it quits the rectum, this portion of the blad-
der ascends almost up to the body of the wound before the peritoneal layer is
reflected over it; a very great advantage, insomuch as that with such an
arrangement of parts we may fearlessly divide the whole vesico-vaginal sep-
tum from the os tinea down to the urethra. It must moreover be remarked,
that as we need have no concern for vesiculae seminales, vasa deferentia, or
ejaculatory canals, the surgeon is much freer to search for the stone, and in
fact has nothing to fear but wounding the ureters, which are placed sufficiently
outwards to be almost always easily avoided.
The female urethra, inspected upon its anterior surface, does not differ as
much from that of the male; still it is covered by the prostatic frenum, no
muscle, and has only the loose cellular tissue which separates it from the
pubis, the small veins which environ it, and the dense filamentous tissue
which attaches it beneath the arch in common with the other. This tissue,
by the bye, is sufficiently remarkable. It is dense, elastic, and possesses a
certain degree of porousness; presenting some of the characters of the yel-
low fibrous tissue, and forming a thick stratum several lines thick, conti-
nuous in front, behind, and also below, with the sub-pubic ligament, and also
with the inferior face of the clitoris which corresponds to the end of the
symphysis. The labia minora, which coming from the corpora cavernosa,
seem to lose themselves obliquely outwards on the inner surface of the
larger ones two or three inches lower down, have between them a triangular
separation, whose summit is represented by a small excavation which divides
the urethra from the clitoris, and through which a bistoury can pass directly
into the bladder. Following their direction and inner edge, lateralized cut-
ting after the method of frere Jacques may be performed. The riieatus urina-
rius may be distinguished amid all its parts by the little tumor which it
forms just above the opening into the vagina. The arteries are so small in
the female perineum as to scarcely deserve the surgeon's attention. The
transverse and that of the bulb are reduced to small twigs; the pudic itself,
very small posteriorly, is extremely delicate long before it terminates upon
the clitoris.
Art. 2. — Examination of the Methods of Cutting.
By some surgeons it has been said, that all lithotome procedures applicable to
man might be equally practised on the woman. This assertion is certainly erro-
neous. The apparatus major for one will never be performed ; and as much
may almost be said of bilateral cutting, at least if done by the lower surface
of the urethra. We have then remaining the lateralized operation, and that
by the apparatus minor and vaginal cutting.
§ 1. Old Methods.
• a. Lateralized method, better called Lateral cutting. — The ancient Greeks,
Arabians, and surgeons of the middle ages, performed lateral cutting in women
as in men. Whilst staffs were not in use, they brous:lit down the calculus
m
NEW ELEMENTS OF
into the neck of the bladder, and held it there by two fingers in the vagina,
or if the patient was a virgin in the rectum, curved like hooks. They then
incised from the integuments towards the bladder all the tissues laying over
the stone, in an oblique direction from above downwards and outwardly from
within. Brother Jacques altered the process merely by using a staff to make
the parts tense, whereby he was enabled to avoid seeking the stone by the fin-
gers in the rectum or vagina. The trials made by this monk before Marechal
andDeMery, having shown, as a correct anatomical knowledge of parts might
have led us to suppose, that the vagina was always wounded and that the
rectum could easily be injured, it was speedily abandoned, so that at present
it is neither recommended by any one nor performed.
b. Method of Celsus or of M, Lisfrcmc. — Celsus expresses himself so ob-
scurely, and with such little minuteness about cutting in the female, that it is
difficult to know accurately what he meant by these words ; "mulieri vero
inter urinse iter et os pubis incidendum est sic ut utroque loco plaga trans-
versa sit." Some, M. Desruelles among others, think that in the days of this
author an incision was made either transverse or semilunar between the meatus
nrinarius and the root of the clitoris, and that through that they went in
search of the stone, as in men is done between the scrotum and anus. But
as lias been remarked by M. Coster, it is not impossible that Celsus had in his
mind the incision into the urethra itself instead of that which 1 have detailed.
It is not clear, either, how surgeons contrived to make the stone bulge out
above the urethra, and it is difficult in such a case to agree literally to M.
Desruelles's version.
From this it would appear that M.Lisfranc's operation, which consists in en-
tering at the vestibule, is not a reproduction from the ancients. It was sup-
ported by M. Meresse, in 1823, at Montpelier, and explained at length in
the Archives for the year 1824, and is done in the following way.
A staff is first passed into the bladder, in such a way as that its groove or
convexity should be turned upwards and forwards, instead of resting as in
man downwards and backwards. Seated before the perineum, provided with
a straight bistoury the surgeon makes an incisionof a semilunar shape between
the clitoris and external orifice of the bladder which skirts the inner surface
of the labia minora, has about the same curve as the pubic arch at its upper half,
and besides includes the vagina in its concavity. He then divides alternately,
and layer by layer, all the tissues which separate the vestibulum from the in-
terior of the pelvis ; comes down upon the anterior surface of the bladder, at the
urethra with the neck of the organ ; strikes on the stafi'; cuts upon its groove,
carries the incision further up turning the edge of the bistoury in that direc-
tion and downwards so as to divide longitudinally the posterior part of the
urethra, or else cut across the reservoir of urine for a length of twelve or fif-
teen lines. As the adhesions of the urethra have all been destroyed by the
anterior incision, it becomes easy to press down this canal and crowd it down
to the lower wall of the vagina, and so create a large space in the upper part
of the pubic arch, of which 1 have many times satisfied myself upon the dead
body. Nevertheless this is a method in many other respects so faulty th^t
we may henceforward assert that it will never be adopted. Do it as you will
the stone must always pass through the narrowest point in the pelvic outline.
The l^lad<ier longitudinally opened can never give passage to calculi of much
OPERATIVE SURGERY. 307
size. If it were divided cross-wise, the inevitable separation of the lips of its
wound in a place so encircled with cellular tissue, would probably not fail to
give rise to infiltrations and abscesses of the alarming nature described when
speaking of hypogastric cutting. We should either have to fear an urinary fis-
tula, or incontinence of urine.
c. Vesico -vaginal cutting. — The idea of extracting calculi through the va-
gina goes back at least to the time of Rousset, as this author states that he
removed in this way eleven from a Moman in whom the bladder projected
at the vulva. Fabricius Hildanus followed the example of Rousset, in a
case in which the vesieo-vaginal septum was partially perforated by the
stone ; then afterwards in another calculus female, whose bladder had been
lacerated during delivery. Ruysch also performed this operation, and removed
forty-two stones from the same female, in whom there was inversion of the
vagina. Tolet did the same under circumstances nearly similar. In 1740,
Dr. Gooch encountered a patient in whom the vesieo-vaginal wall had been ulce-
rated by inflammation, into which he cut to remove a stone which weighed
three or four ounces. M. Faure of Limoges transmitted to the faculty at Paris
in 1810 a piece of wood which he had removed from the bladder of a young
girl by an incision through the vagina. M. Clemot, a surgeon of Rochfort,
performed it for the first time in 1814, upon a young female aged twenty-one ;
and soon after repeated it upon another patient. Since then he has a third time
had recourse to it. At a rather later period M. Flaubert of Rouen, performed
the same procedure to extract a needle and a pin which had become the nu-
cleus of a stone in a child eleven years old. In 1816, he operated on a female
thirty-three years old, who had a calculus as big as a nut; afterwards upon
another one aged forty, in whom the stone was nearly as large as a billiard
ball. On the lOtli Dec. 1818, he did it a fourth time upon a woman twenty-
one years of age and removed a stone as big as a large nut. M. Rigal de
Gailiac, also operated per vaginam, in 1814, upon a woman forty years old in
whom the stone weighed two ounces and a half. The same surgeon performed it
once several years previously, in a woman thirty-eight years of age
who for eight years had had a considerable stone. A recent example has been
recorded by M. Lavielle ; and M. Rigal, jr. has lately communicated another to
the Academy. So that we have now about twenty" cases of vesieo-vaginal cut-
ting, not including two attributed by Dr. Gooch to surgeons of his country,
about which he gives no particulars.
The method ojf Operation^ — Many of those who have performed this opera-
tion, are silent as to the procedures which they adopted. F. Hildanus who
first formally proposed it, advised that a scoop of very small calibre should be
carried into the bladder through the uretlira to embrace the stone in its spoon
and press it down towards the vagina, drawing it to the neck of the bladder,
so that the surgeon, cutting down on the projection which it makes in the
vulvo-uterine canal, may extract the stone by tnis passage. The procedure
of Mery, which consists in substituting for the scoop recommended by Fabri-
cius, a common staff, so as to divide the vesieo-vaginal partition upon its
groove, must forever have done away with the adoption of that of the Swiss
surgeon. Indeed it is this operation, modified, which modern surgeons
pursue; some by the addition of a gorget, by the outer end of which
they depress the vaginal posterior wall, whilst the other end butts against the
808 NEW ELEMENTS OF
staff in front of the cervix uteri : others like M. Flaubert, for instance, con-
Uning themselves to carrying in the bistoury flatwise on the 'right forefinger,
then turning its edge upwards and cutting the septum from before backward
or from behind forwards to a greater or less distance from the meatus urina-
rius.
Position of the Patient. — It is undoubtedly possible by placing the woman
in the position for ordinary lithotomy, to attain the proposed end. However,
I think that if she lies upon the abdomen with the thighs and legs flexed, it
would be easier still to perform the necessary incisions.
The instruments necessary are merely a staff', a Marchettis*s gorget, a straight
bistoury and forceps. The staff" is first introduced, and its handle elevated
towards the pubis, so as to depress the bas-fond of the bladder upon the
median line. An assistant is entrusted with keeping it in the situation. The
gorget introduced to the bottom of the vagina is given to a second assistant,
who depresses the handle, being careful to make it a fulcrum for the staff* at
its other extremity, and that its groove should look upwards and forwards
when the woman lies upon her back ; and backward, on the contrary, if she
is placed on her abdomen. The surgeon separates the labia majora with
the thumb and first fingers of his left hand : takes his bistoury, holding it like
a pen : carries its point behind the urethra, that is to say to a depth of an
inch into the vagina at least ; strikes it into the groove of the staff', slips it
along upon this instrument to an extent of eight or ten lines or more if neces-
sary, and ends his incision by lowering the knife a little ta make it fall into
the groove of the gorget.
It may also be held in the second position : i. e. the hxindle in the hollow of
the hand, and the cutting edge towards the bladder, so that its p^int may
enter as deeply as may be desired to divide the septum from behind forwards,
still upon the groove of the staff". These two modes diff'er so little in their
definite result, and in the ease with which they are effected, that we must
leave the preference of one over the other to the taste of the operator. There
can be no doubt, likewise, that the surgeon may himself hold the staff* in his
left, whilst he makes the incision with his right hand, as was done by M. Flau-
bert, or else as M. Clemot recommends he may take charge of the gorget
instead, so as not to be embarrassed by his assistant whilst dividing the sep-
tum; in truth, we may do without the gorget altogether, in imitation of the
surgeon of Rouen, and carry in the bistoury, covered by the inside of the fore-
finger into the vagina ; so as to open the bladder without any other assistance
than that of the persons who attend to the patient. Yet it cannot be denied that
the operator who has both hands at liberty, will be more at his ease in perform-
ing his principal incision, and that the gorget has the advantage of rendering
tense and exposing the parts which are to be divided ; only it would be well
that this instrument should have a handle bent at an angle, the groove ending
in a cul-de-sac. There is this inconvenience in the procedure of M. Flaubert,
of beginning the incision some lines behind the meatus urinarius, so as to in-
clude a greater or less extent of inner wall of the urethra: first, that it inno-
v/ise assists the exit of the stone, and then that it renders cicatrization of the
wound long and difficult. It is better then to follow MM. Clemot, Rigal, and
others, and to begin it only at the apex of the trigone vesicale if we cut from
before backwards, or to terminate it at that point if we prefer incising from
behind forwards. The vagina being four or five inches in length, we have
OPERATIVE SURGERr. 809
still by this procedure an extent of two inches which may be divided without
any danger. Besides as these tissues enjoy a considerable distensibility, it is
useless to make a larger aperture than the presumed size of the stone would
require.
Extraction of the Stone. — The incision being made, the staft" is withdrawn.
If the stone do not of itself oifer at the wound or fall spontaneously into the
vagina as sometimes happens, the operator proceeds at once to investigate its
situation and character by the assistance of his left forefinger; and then
extracts it with proper forceps pursuant to the rules previously established.
When the stone is very bulky, and we are operating on a young girl, the
narrowness of the vagina may offer some difficulty in the extraction. In a
case of this kind, M. Flaubert was obliged to break the foreign body and
remove it piecemeal. However, as the canal which we have to traverse is
easily dilatable, it is scarcely possible to suppose that it can be an insurmount-
able obstacle to the termination of the operation of cystotomy.
Having removed the stone the woman is replaced in bed, and subjected
to the care necessary in the usual sequeli of operations for calculus.
The consequences in the vesico-vaginal method are usually very simple.
Hitherto no case is related in which they have produced death. Generally
not even fever attends them. No large artery can be opened. The peri-
toneum is too high up to run any risk, and the cellular tissue in the septum too
dense to admit of urinal infiltration. The wound, however, does not always
heal in a way to please either the surgeon or his patient. Its location alone
might have induced the supposition that it would turn frequently to fistula,
and experience unhappily confirms the conjecture. Without including in the
account any of the patients first operated on, who continued to be afflicted
with it, though it is not mentioned in the reports of their cases, it is certain
that in three cases M. Clemot saw it once ; that three patients treated by
M. Flaubert are affected with it; and that the one whose case M. Rigal,jr.
related, was not more fortunate; whence it follows that this occurrence
takes place once in four cases. M. Coste thinks that it might be avoided by
approximating the edges of the wound by suture immediately after the removal
of the stone ; but then vaginal cystotomy would be rendered an extremely
long operation ; and we may even entertain some doubts from our experience
of such attempts for the cure of vesico-vaginal fistula of the common kind,
whether we should derive from it the success upon which this surgeon seems
to calculate.
§ 2. Urethral Methods for Extracting Stones,
For many years past, perineal lithotomy in the female has been done
almost entirely by cutting into the urethra. This canal is so very distensible,
that for a long while it was thought practicable to remove stones from it
w'ithout any sort of incision. Bartholin speaks of a patient who expelled a
calculus of the diameter of more than two inches ; Borelli of another which
was as large as the thumb. Middleton relates that in a fit of coughing a
woman passed one which was four ounces in weight. Heister has collected
some examples of the same kind, in which it will be seen that a stone as
big as a nut or even as a hen''s egg, passed through the urethra by natural
102
SWI NEW ELEMENTS OF
-eflbrts alone. Francis Collot mentions one of the size of a goose egg, which
occasioned ischuria of eight days' continuance. Molineux states that he has
seen one which weighed two ounces and a half; and that of which Yeloli
speaks, weighed upwards of three. In conclusion, some even still larger are
recorded in the bibliotheque of Planque. Kerkringius, Morand, Grunewald,
and the scientific compilations both ancient and modern contain many more not
less extraordinary. Although many of these stones may have come from the
uterus and vagina, and not have formed in the bladder, it is incontestable
nevertheless that many among them were really expelled per urethram, and
that in certain cases this extreme dilation has not been followed by inconti-
nence of urine.
a. The Method by Dilation which arose upon these observations, is done in
two principal ways ; in one we proceed rapidly by means of metallic instru-
ments ; in the other, on the contrary, it is done with extreme slowness, and
by the aid of pervious bodies for the time left to remain in the canal. The
author of the first of these plans is Tolet, and Douglas that of the second.
Sudden Dilatio7i. — The procedure of Tolet consists in introducing the
dilating instruments of the greater apparatus into the bladder, and gently
separating the branches until it is possible to pass in both fingers and forceps
between them and thus extract the stone. The old dilators have since been
superseded by the following procedure. A grooved sound acts as a director
to a gorget whose anterior portion is narrow which rapidly grows thicker
towards its handle. By its assistance, the fore or little finger ®f one hand
then enlarges the urethra from before backwards, to create a passage for the
forceps; in what way soever this operation be attempted, it is so extraordi-
narily painful that many women cannot endure it, and it is, moreover, often
followed by incontinence of urine, laceration of the urethra, &c.
Slow Dilation. — Douglas thought that he could do away the inconveni-
ences in Tolet's method of rough and sudden dilation by effecting it with a
sponge tent or a dried root of gentian. To this day this plan is pursued by
those who think it possible to dispense with incising the urethra. The cjdin-
der made of the coecal appendix, introduced collapsed into the bladder filled
with water and then drawn forwards from behind as Bromfield advises ; and
the same kind of dilator contrived by M. Arnolt are not more advantageous ;
and a sponge even has this advantage, that it allows of our placing in its mid-
dle a catheter which will give exit to the urine in cases in which it is neces-
sary to retain it long in the part.
It would be wrong to suppose after all that this species of dilatation was
much less painful than the other, or that it protects the patient against incon-
tinence and the many other accidents which the former is accused of' causing
It is very certain that pure and simple incision, as it is now performed, brings
with it no more danger, causes less pain, and allows of a more speedy relief
to the patient; so that dilation, whether slow or sudden, is suitable only to
such stones as do not exceed five or six lines in their smallest diameter.
b. Urethrotomy. — Incision of the urethra may in fact be performed at any
part of the two upper thirds of the circumference of this canal.
Fleurant has proposed to divide it on both sides at once with a double litho-
tome introduced closed, and withdrawn open ; beginning the incision at the
neck of the bladder and terminating it at the meatus urinarious. , Lewis,
OPERATIVE SURGERY. 811
who adopted the same method, preferred cutting from before backwards. For
this purpose he had invented a flattened sheath open on the sides, into which
passed a double edge-cutting instrument from without inwards. Le Blanc,
to whom he communicated his project, suggested to him that an instrument
which cut, or a sheath which was open only on one side, would do equally
well. But all the procedures done with the like instruments are now fallen
wholly into disuse, and all that is necessary for performing cutting of the
urethra is a straight bistoury, a grooved staif, or a brother Gome's lithotome ;
unless indeed we renew Fleurant's proposal, when Dupuytren's double litho-
tome may find a new application. The oldest method, and that which has
been longest pursued, is that which consists in passing a grooved staft* into
the bladder to act as director to a long straight bistoury with which the whole
extent of urethra is obliquely divided from top to bottom, and from right to
left. But this procedure, which has been simplified by F. Come and M. Du-
puytren by the use of a sheathed lithotome instead of the bistoury and staff, was
often followed by wounds of the vagina, and also admitted of a division of
the superficial vessels of the perineum, a swell as of the pudic artery itself
if the incision were extended a little too far, and it has owing to these circum-
stances been generally abandoned since the adoption of the plan of cutting
the urethra directly from above downwards. The date of the origin of the
last method goes back at least to the sixteenth century, though attributed to
M. Dubois. Pare gives the credit of it to Collot ; after having given a plate
of the grooved staff, he says: ** Other practitioners operate in another way,
as I have seen master Laurent Collot do often ; which is not by putting the
fingers into the breech, nor into the neck of the womb, but by simply placing
directors in the urethra; then after, they make a small incision, quite above
and in a straight line from the orifice of the neck of the bladder, and not
on one side as is done in men." As revived by M. Dubois it is now executed in
like manneras the former, with a bistoury and staff, or with a sheathed lithotome.
In the first case we introduce a stout staff, the groove turned uppermost, and
ending in a cul-de-sac. The surgeon holds it by the handle in his left hand,
and with it presses down the forepart of the vagina forcibly. With the right
hand he passes in a straight and sharp bistoury upon it, with which he incises
the upper wall of the urethra in all its length, and the surrounding tissues as
far as the sub-pubic ligament. Thus we obtain an opening of six or eight
lines, which is sometimes increased to eight or ten, whilst tractive efforts are
being made upon the stone. It would not be safe however to attempt the
removal through it of a stone of more than twelve or fifteen lines in size. I
have seen one of these dimensions extracted by M. Bougon from a young
woman who perfectly recovered ; and M. Thomas of Tours was not less for-
tunate in a similar case. It is of consequence when we withdraw the forceps
to press strongly against the inferior plane of the canal, and to raise the han-
dles sufficiently to make them act in the axis of the lower strait. Otherwise
the stone and the blades of the forceps also will be stopped behind the symphysis,
and the surgeon will create an insurmountable difficulty, while he at the same
time exposes the woman to dangerous contusions. A good operator was for
a long time delayed by this obstacle in 1824 in one of the hospitals of Paris,
and after all the stone, which was easily extracted when the direction of the
forceps was changed, was no bigger than a partridge egg !
812 NEW ELEMENTS OF
Art, 3. — Hecapitulation.
From this detail it appears that no species of perineal cutting on the female
allows of our extracting large stones. The lateral incision, or the lateralized
itself, could not in this respect be of much service. The upper incision,
being situated in the pubic arch at the top, necessarily gives a very small
opening. A bilateral incision without any doubt would offer greater advan-
tages ; but as yet experience has not proved that it could be practised with
any chance of success ; and reasoning strongly leads to the fear, that to sepa-
rate thus the urethra into two parts would cause fearful urinous infiltrations,
or produce an incurable incontinence. Still I think with Dupuytren, that it
would be well to take this question into consideration and decide it by the
authority of facts. When we consider that in the female sex lithotomy is
most often called for by large stones, we must choose between hypogastric
cutting and that per vaginam. Fistulas, which too frequently follow the first
method, are so disgusting an infirmity, and so generally incurable, that we
shall seldom decide on adopting it until quite sure that we can succeed by no
other. Now, cseteris paribus, the other being the easier because of the lesser
height of the pubis, and the greater rise of bladder above the strait of the
pelvis, and having always seemed less dangerous than in man, it should, I
think, be preferred in every case in which the bladder retains its dilatability ;
inasmuch as that those calculii which we cannot extract by incision of the
urethra will require a too large opening in the vesico-vaginal septum for us
not to fear the production of a fistula. To sum all up, it appears to me that
dilation will do for small stones — the upper incision for those which are not
larger than a small egg — that the oblique incision should be attempted if the
stone is only a little bigger, or if the vagina is not dilated by it to a degree
which makes its lesion almost inevitable, whilst vaginal cutting is proper only
for stones as large as a hen's egg, or at most a turkey's ; supposing that we
are on no account willing to go above the pubis, which operation is however
the only one after all which is suited to stones of a still larger size.
It is useless to add that the position of the patient, assistant^ and operator —
the apparatus — the precautions necessary in extracting the foreign body, and
the consequences of the operation, are similar, or nearly, to those which have
been under the same circumstances in the male.
Relative Value of the Different Modes of Cutting for Stone in the Male.
One question yet remains to be answered ; it is to know which of the me-
thods deserve to be adopted as a general one in preference to the others. To
solve the problem we must first consider to what circumstances the fatality of
the operation for stone is owing in patients who fall victims to it. Many
perish from hemorrhage. Others die from inflammation, abscess, sphacelus
of the pelvic cellular tissue, and of peritonitis. Some seem to be hurried
into the grave by organic affections, more or less distant from it; such as
diseases of the brain and viscera, ataxic and adynamic symptoms ; serous or
purulent effusions in the pleura, and especially numerous abscesses of the
parenchymatous organs. Besides these lesions there are others which are
OPERATIVE SURGERY. 813
infirmities merely; sucn are incontinence of urine, division of the rectum,
and urinary fistulse of every kind.
Recto-vesictd cutting is, it is true, less liable than any other to pelvic sup-
puration, and to metastatic abscesses. But it is more often followed by
phlegmasia of the bladder and intestines. It undoubtedly most often gives
rise to urinary fistulae, and does not allow, as is generally supposed, of safer
extraction of large stones than any other method.
Hypogastnc cutting can be attended with hemorrhage very rarely — it is
safe from fistulse — almost always from inflammation of the bladder, from in-
continence of urine, intestinal phlogosis, and the multiplied foci of suppura-
tion in distant parts. It allows of the extraction of very large stones, and is
not difficult to perform ; but the wounding of the peritoneum is of itself alone
a very alarming accident, for if an inflammation of this organ ensues death
almost always follows. It must, besides, be added, that no where are abscess,
gangrene in the cellular tissue of the pelvis, and infiltrations more to be
dreaded ; and that no where have we less means of avoiding them.
Perineal Cutimg, which exceeds the limits of the prostate, exposes the
patient, though in a less degree to similar infiltrations, to wounds of the
rectum in some cases ; to recto-vesical, recto-urethral, or simply urethral fis-
tulse ; to incontinence of urine ; and also to metastatic suppuration in a greater
degree than the two preceding ones ; which is, I think, in part owing to its
dividino* large veins which inflame and also to small abscesses formin";
about the wound, the pus from which in some way or other enters the general
circulation. As it is confined within the circle of the gland, it allows readily
of our avoiding both arteries and intestine; can be but seldom followed by
idiopathic or symptomatic abscess, and really has no other objection than that
of not allowing a large enough passage for very large stones. In that' case
the bilateral operation or the multiplied openings of the -method of M. Vidal
will furnish i^s with a suflicient resource; and incontinence of urine or the
fistulae urinariae, which in this case might be dreaded, are neither frequent
enough nor so difficult of cure as that we need be much afraid of them: so
that perineal cystotomy is after all that which possesses the greatest advan-
tages, and which is entitled to conclude our analysis to the preference as a
method of general adoption.
Recto-vesical cutting will be adopted only, as I think, as an occasional
exceptional method; in cases, for example, wherein tumors, ulcerations,
and alterations of greater or less depths in the perineum do not allow of our
going through this region ; or else, when the stone is found fastened to one
end in the prostate ; in diseases of this gland, as ulceration, or when it is'the
seat of an excavation which would make it dangerous or difficult to attempt
an incision upon its sides ; or when the stone seems to have thinned or ulce-
rated the recto-vesical wall itself. The high apparatus should be reserved
for performance on very large calculi occurring in children and in women,
when the bladder can be easily distended or the operation is not rendered
difficult by the eynhonpohit of the patient. However, it is worthy of remark,
that if obesity be an obstacle to hypogastric cutting, it has on the other hand
the advantage of removing the peritoneum from before the knife, by means
of the quantity of fat which usually accumulates between it and the parietes
of the abdomen. In case of meeting with horny hardness or thickening of
814 NEW ELEMENTS OF
the walls of the bladder, we must consider them as belonging to the list
which justifies recto-vesical lithotomy, unless perineal cutting can be applied
to them.
D. Nephrotomy,
Our science is possessed of numerous cases of stones retained in the kidneys
themselves ; and there acquiring considerable development, so as to cause
the death of the patients. Hence the idea of nephrotomy has originated,
which may be defined the incision of the organ through the healthy tissues-
and that of an abscess upon the stone which may be felt through the lumbar
region : or else, the mere enlargement of urinal fistula, with a view to favor
the exit or extraction of the foreign body. One cannot deny that it may be
possible to come upon the urinary gland by its posterior surface, by dividing
the soft parts of the side between the last rib and crest of the ileum on the one
hand, the sacro-lumbar mass, and posterior edge of the oblique muscles on
the other. I have often succeeded in pursuing this plan, and my opinion
with regard to it is perfectly in accordance with that of M. Gerdy.
But when it is remembered that it is scarcely possible to be satisfied that
stone exists in the kidney by any physical means, and that all its rational
signs are more or less deceptive; when we reflect again, that though its pre-
sence even be admitted, it is yet to be ascertained whether it occupies the
entrance of the ureter or the pelvis of the kidney, instead of the thickness of
one wall of the organ. Whether it is or is not accompanied by ulceration, by
purulent secretion, in short, by any disorganization whatever, we must re-
nounce nephrotomy so often as no external appearance shall indicate the
point upon which our search should be begun.
There is, moreover, no proof of its ever having been attempted. The
passage cited from Hippocrates I do not think refers to it. The much
boasted operation on the bowman can have no weight in such a matter;
for it is a circumstance which may well be a sheer fabrication. Who
can place any confidence in it, when it is seen that Mezerai makes this cri-
minal come from Bagnolet, while Monstrelet places him at Meudon ; that
some authors rank it under the reign of Charles VII ; others under that of Louis
XI ; that CoUot and the author of the History of France are of opinion that it
was to nephrotomy that he was subjected; Rousset and Sprengel that he
was operated on by thfe high apparatus ; Mery that he was cured by perineal
cutting, while Toilet asserts that it was gastrotomy to remove a volvulus ?
The case of Hobson, the consul, is not more conclusive, upon whom it is
said to have been performed by Marchettis. Bernard, who relates it, had no other
authority for the fact than the statement of the patient and of his wife, and
yet Marchettis says not a word about it in his '' I)^ Observaiions Bares J^
It is to be hoped, that the discussions originated in the schools of surgery, in
1784, by Masquelier and Bordeu, and Coussinot a century before, to settle
whether nephrotomy was applicable or not, will never again be revived. It
can be proposed with propriety only in the very few cases in which the side,
presenting evident fluctuation after numerous symptoms had existed of calcu-
lous affection in the kidney, will allow of our reaching with facility and cer-
tainty the focus of disease; again, in such as are attended with a fistulous
OPERATIVE SURGERY. 815
ulcer, which allows of the stone being touched with a sound; and lastly,
in which the calculus itself projects outwardly, and may be detected througli
the integuments.
The operation then becomes so simple, so trifling, and must be varied to
suit so many circumstances, that it would be useless to describe it in detail.
All that can be said about it is, that having made our opening large enough, or
having sufficiently increased that which previously existed with a bistoury
alone, or directing it upon a grooved conductor, we must seek with caution for
the stone, and extract it either with common forceps, polypi forceps, dressing
forceps, hooks or scoops ; or sometimes the fingers alone will suffice.
Calculi impacted out of the Bladder.
1st. In the Ureter. — What I have just said of calculi fastened in the kid-
neys, applies with greater force to those which are impacted in the ureters.
Although they may be retained at any part of this duct in its whole length,
it is especially in its upper third, and towards their vesical extremity, that
they are met with most frequently. They may under the first of these cir-
cumstances ulcerate and pass in part into the cellular tissue of the side and
so create an abscess, which may be opened above the crest of the ileum, or
make its own way through this region. A patient, who died quite suddenly
in my department at La Pitie last year, offered a remarkable peculiarity,
which the reader perhaps will not be sorry to see inserted in this place.
The kidneys were in a perfectly healthy state, as were also the left ureter
and the bladder which contained no stone ; but the right ureter, largely dilated
for about three inches below its origin, was perforated behind by a stone as
large as a nut, which projected into the cavity, and extended outwardly at the
bottom of an abscess beneath the ascending colon. In the centre of this cal-
culus was a pin. The stone appeared to have caused all the great thickening,
induration, engorgement, and suppuration even of the cellular tissue and
muscles, which extended from the kidney to the bottom of the pelvic cavity,
so as almost to close up entirely the lower strait of the pelvis.
This stone, as I satisfied myself on the dead body, might easily have been
extracted through the flank of the same side. But who could have assured us
of its existence during the life of the patient, and who, without such certainty
and on mere suspicion, would have ventured to perform such an operation ?
2d. In the thickness of the Vaginal Septum. — If a calculus concretion forms
between the urethra and vagina, of which M. Macario relates a case, and its
presence can in any way be determined, its extraction should be effected by
incising through the viilvo-uterine passage, and to a suitable extent the thick-
ness of cyst separating it from the urethra.
Sd. In the Prostate Gland. — The gland which surrounds the commence-
ment of the urethra suppurates and ulcerates very frequently. Urine, by
being effused in the small hollows which are thus formed, may deposite gra-
velly particles susceptible of acquiring more or less considerable dimensions.
At other times calculi stop, and are fastened simply in the width of the canal
which it encloses. These may either be pushed back into the bladder or
seized with a forceps fitted with a sheath {pince a gaine) and drawn out; or
816 NEW ELEMENTS OF
they may be broken into pieces in situ. On the contrary, the others can be
seized through the urethra but with very great difficulty. We are obliged to
seek for them through the perineum. The same is to be said of those wliich
are formed sometimes in the substance of this region ; either after the opera-
tion for stone when some fragments of gravel have been caught in the wound,
or when a small calculous concretion has escaped into the adjoining tissues,
owing to some laceration or to an ulceration of the urethra. The position of
the patient is the same in perineal cystotomy. After the introduction of the
catheter, where no impediment exists we are to seek anew to determine pre-
cisely by the finger the position of the stone. The operator then cuts upon it
and lays it bare. If he does not think the first incision large enough, he
enlarges it by commencing at its angles, protecting his instrument upon a
director. The extracting agents then are the forceps, the scoop, or the fin-
gers. On this subject Louis's memoir, inserted among those of the academy,
may be advantageously consulted.
4th. In the Urethra. — Stones are met with in every part of the excretory
duct of the urine, in which, when of any siz,e, they speedily give rise to very
serious difficulties. When stopped behind the meatus urinarius, or in the
fossa navicularis, it is seldom that the gush of urine and the eflforts of the
bladder are insufficient to expel them. If it be otherwise, however, we are
to seek for them with a pair of dressing forceps, having a beak somewhat
flattened and concave ; or, as Sabatier advises, by slipping beneath them a
loop of some metallic wire, brass for example ; and else by the aid of a small
scoop, of a hook shape, as was done by M. Civiale in the case of M. Boissean
in September 1828 ; and lastly, if all these means are attended with too much
difficulty, by incising the lower wall of the urethra in front of the stone, by
carrying a narrow bistoury into the canal, and bringing it back from behind
forwards; unless we prefer to make use of a sort of sheathed bistoury, such as
is used by M. Civiale under tlie name of uretrotome. One indispensable pre-
caution, whatever be the mode we adopt, consists in fixing the penis firmly
with the thumb and forefinger behind the calculus so as to favor its expulsion,
or at least to prevent it from being pushed backwards by the instrument.
When the stone is locked in the beginning of the spongy portion which, from
the gradual construction which the canal experiences hereabouts, is often
seen, the surgeon in like manner fixes the hinder portion of it with one hand,
and with the other endeavors to withdraw it with the metallic loop of Sabatier
or of Marini, such as M. E. Rousseau has recently employed with success.
This not sufficing, we resort to the pince a gaine^ having denticulated grasps
made thin, firm, and concave, and only separating when they arrive at the
anterior surface of the stone to dilate the urethra as it were, so that the foreign
body when pressed by the finger may come easily between them. To be sure
that we have it, and that we may not uselessly close the forceps, M. Civiale
advises that they sliould be traversed by a stylet, the head of which opens the
forceps when withdrawn towards the sheath. The operator feels with this
stylet where the stone is, displaces it when it is unfavorably grasped, and
runs no risk whatever of injuring the patient. When it is once firmly seized
it is drawn out, slowly if rather large, and so as if possible not to produce
the least tearing. If the size of the calculus renders it difficult of extraction,
which it seldom does as it can hardly have been long enough in the urethra to
OPERATIVE SURGERY. 817
have increased much in size, its fracture, if fragile, must be eflfected, or else
it must be drilled with a perforator for this purpose carried in instead of the
stylet, so that it may afterwards be more easily cruslied.
Calculi, which are arrested in the bulbous portion, are to be treated upon
similar principles. In the membranous portion, where nevertheless they are
found most frequently impacted, more difficulty will evidently be experi-
enced. If the preceding attempts which may be modified by a change of
instruments, by using for instance a forceps more or less curved, all fail,
and the affection is urgent, incision into the urethra becomes our sole resort-
It is the same also in the other cases we have pointed out, in which drilling
and extraction are only measures to be first tried.
Incision having become decidedly necessary, it is thus performed : When
stone occupies the second portion of the urethra, an assistant is to keep it
fixed there by the introduction of two fingers into the anus. The surgeon
with a straight bistoury, divides the integuments previously well stretched,
then the cellular tissue, then all the parts contained in the base of the recto-
urethral triangle, and comes down upon the foreign body. Having sufficiently
enlarged the incision, he extracts the calculus with the assistance of suitable
instruments, and for fear there should be others in the bladder, prostate, or
in the remainder of the urethra, he examines all these parts with a grooved
staff, a female staff, or any species of catheter. Behind the scrotum the spongy
portion of the urethra has such movable coverings that they are in general
easily enough divided. For this reason it is proper to carry a grooved and
^y strong staff through the natural passage to the stone ; to raise the scro-
tlmi as much as possible; sedulously to stretch the integuments ; to have the
stone supported behind by the fingers of an assistant, and make t!ie incision
into the integuments longer than that into the urethra itself. The object of
this, is firstly to come more surely on the foreign body; secondly, to prevent
infiltrations. The same course is to be pursued for stones which lie in front
of the scrotum, save that the scrotum has then to be crowded down towards the
anus. It is important in these cases not to open the urethra at first at more, than
one point over the stone, and then to enlarge the incision on a director back-
wards or forwards. By an opposite procedure we should produce a jagged
wound, with edges more or less fringed, far from favorable to cicatrization,
v^hilst the latter mode produces one which is very even, and tiie fittest possi-
ble for instant adhesion, or at least for a very speedy one.
As to Phila^rius's advice, who recommends in order to avoid fistula that
we should open into the urethra through the dorsuni-penis, it would be found
applicable only for very small stones stopped in front of the scrotum, and I
do not think that even at any rate it will be revived. Besides is it quite
certain that Philagrius meant to speak of opening of the urethra rather
than calculi and opening of the bladder ? Moreover, fistulas after incision
into the urethra such as I have often described, are much less frequent than
one might have supposed. M. Civiale relates the case of a patient ope-
rated on at La Pitie, by a pupil at that hospital, who had three bulky
stones in the bulbous, membranous, and prostatic portions of the urethra.
The operation was long, laborious, created a very uneven wound, yet was
not followed by a fistula. The division heals of "itself, and only requires
as perfect coaptation as possible to be maintained between the different layers
103
818 NEW ELEMENTS OF
through which it^ goes, and to be covered with lint spread with cerate. It
is of no benefit to leave catheters in the bladder, which indeed interfere with
the recuperative eiforts of the organization.
5th. Betiveen the Gland and Prepuce.- — Children are, as we have said, very
subject to contraction or stricture of the preputial opening, and the covering
of the glans penis in them is naturally very long. From this it results that
the urine spreads into it as into a sac before it escapes outwardly on leaving
the urethra, and that it there forms frequently stony concretions, which are
also, though much more seldom, seen among adults. They may acquire a
a size which is truly astonishing. Morand preserved one which was as large
nearly as an egg, and which had a furrow on its upper surface for the passage
of urine. Sabatier was the owner of another which was larger still. The
extremity of the penis on these persons is swelled, heavy, and dependent like
the clapper of a bell. Their removal is extremely easy. All that is required
is to introduce a director between the foreign body and the prepuce, on which
a bistoury is passed down, which cuts and divides the tissues from within
outwards. This might as well be done from without inwards by acting per-
pendicularly on the calculus. An operation of this kind made a great noise
in Switzerland at the beginning of the last century, and was said by some
persons to be a case of super-pubic lithotomy.
§ 2. Lithotniy,
Cutting for stone is still so dangerous, notwithstanding the many improv
ments it has undergone, that efforts are constantly being made, to render
unnecessary, and to substitute for it some operation of a less cruel nature.
There are many who think that this desirable end has at length been attained
by modern surgery ; and that by means of lithotrity we may for the future,
in a very great majority of cases at least, dispense with performing lithotomy.
We shall see as we proceed how far such hopes may perhaps be entertained.
Lithotrity, or the breaking of a stone by grinding and bruising it, consists
in the comminution of a stone into fragments, and their extraction per vias
nahirales^ by means of particular instruments for that purpose. In its widest
j^ignification it comprises pure and simple extraction, crushing, pulverization,
breaking by bruising, perforation and trituration of stones, even within the
interior of the bladder or urethra. The names of " lithoprinia, lythodyalisie,
lithotripsy, lithocenosis," which it has been wished to substitute for lithotrity,
being no less liable to objections do not deserve the preference which has
been claimed for them by their inventors.
»^rt. 1. — Historical Account,
The idea of extracting calculi, either entire or after having been broken,
without an incision of the parts is not by any means a new one. For tliose
at least which were arrested in the urethra it has in every age been suggested.
Albucasis mentioned an instrument which enabled him to seize them at
the bottom of this canal. The sheathed forceps with three or four branches,
described and delineated in the Bibliotheque of Manget under the
name of Asta, appeared to Fabricius Hildanus, suited to the same end. A
OPERATIVE SURGERY. 819
tube with three elastic branches, was in the same way made use of by Sanc-
torius. Franco with this view had contrived a •* quadruple vesical," and
Pare a sort of trepan or elevator, " bis-fond," which he passed down to the
stone through a canula. Fabricius Hildanus employed a forceps with three
branches, which after it had grasped the stone was capable of breaking it.
Still, though it has appeared easy to all authors almost to sei/.e small calculi
to pierce and break them in the urethra, it is not quite so clear tliat they ever
carried their instruments further on to fulfill the same intent. However, an
Arabian author, who is evidently no other than Albucasis, in a work in which
the names of Alsaharavius or Acaravius, are given him, says that we must
introduce softly a subtile instrument called ** maschabarebilia" into the blad-
der, to seize the calculus, crush it if soft enough, and extract it. Alexan-
der Benedictus also says that a stone may be crushed with metallic instru-
ments without any wounding of parts. Lastly it appears that Sanctorius,
Franco, and Fabricius Hildanus, also were accustomed to search for small
stones even into the bladder; but the very imperfect details which they have
left of their proceedings, are too vague to be of much weight upon the sub-
ject.
During the last century, Hoin of Dijon related the account of a monk at
Citeaux, who by means of a flexible tube, and a stem of iron sloped at its
extremity, succeeded in breaking a stone under which he labored, by striking
on it by quick and small strokes with a mallet, as on the chisel of a sculptor.
The journals of Calcutta, and subsequently M. Marcet, have made known
a fact even more conclusive; that of Colonel Martin who died in 1800, who
succeeded in his own case in reducing a calculus to powder by means of a
metallic stem which ended in a file, and was introduced into the bladder
through a curved catheter. I have been unable, as was M. Civiale, to meet
with the work of Dr. Marco, published at Venice in 1799, and entitled *'a
New Method of dividing a Stone in the Bladder." The forceps invented by
Hales, and called Hunter's, enabled Desault to take out three vesical calculi
of very small size, and Sir A. Cooper, who modified it, removed with it
in this way about eighty from the bladder of a chimney sweeper.
None of these however constituted regular methods; and in spite of the
much more systematic labors of M. Gruthuisen, Mr. Eldgerton, who also
endeavored to break the calculus within the bladder, still employed a curved
catheter into which he introduced a rasp, which by a motion backwards and
forwards, should wear away the stone. The plan of Gruthuisen, though
unapplied and perhaps inapplicable, at least went further than any other.
This gentleman delineated numerous instruments, made multiplied experi-
ments, and clearly demonstrated that straight canulaa, 4, 5, and 6 lines in
diameter could be passed through the urethra. Altliough its chief object
was to decompose them by galvanic action, he notwithstanding invented an
instrument to break them ; the apparatus consists of a large straight canula
of a loop of brass wire, which enlarges at the vesical end of the tube, and of
a perforator which may be pushed out and withdrawn at pleasure. The
surgeon seizes the stone in the loop of wire, draws the wire towards him so
as'to bring the calculus against the beak of the canula, then taps and perfo-
rates it with the drill, which is turned by a bow.
The attempts made by Gruthuisen had, like those which preceded them,
820 NEW ELEMENTS OF
nevertheless sunk into oblivion, when several of our fellow-countrymen,
impelled bj the same necessity, engaged in an attempt to establish lithotrity»
Here a difficulty presents itself for solution; to whom belongs the credit of
being the original founder of lithotrity as it is now performed ?
M. Civiale, who since 1818 had been engaged in searching for a method
of dissolving stones in the bladder, and had conceived an idea of some
instruments for seizing and breaking them, asserts that he invented those
which he now employs. M. Leroy d'Etioles, on the contrary, declares that
then M. Civiale had only invented some instruments which were inapplicable
to the end ; and that he was entirely ignorant of the (" pince") forceps with
three elastic branches, which is merely a modification of that of Sanctorius,
or the ball extractor of Alphonso Feri. I indeed remember that M. Leroy
showed me the forceps which is now in daily use before he laid it before the
academy, in April 1823 ; and that which is to be found in M. Civiale's first
book, published in the course of the same year, differs exceedingly from it,
and much more resembles the quadruple vesical of Franco. Still it is very
difficult to take any side in this affair, particularly as Percy, in his report to
the academy of sciences, in 1824, decided wholly in favor of M. Civiale;
whilst in the years 1825, 1828, 1831, the same learned body awarded to M. Le-
roy the prize for inventing the principal instruments, among others the three
branch forceps now used by almost every lithotritist. The detail of the
various procedures actually adopted, and of the different instruments which
have hitherto been used, will oblige us to return to the question, and enable
us also to decide more equitably upon it.
Art, 2. — Examination of Methods.
Lithotrity comprises two methods distinct from each other, as to the appa-
ratus which either requires : the one necessitating the use of straight, the
other that of curved instruments.
§ 1. The Rectilinear Method.
One of the difficulties which longest opposed itself to the practitioner was
to penetrate to the bladder with straight stems; so that lithotrity has in
reality been created from the period when the possibility of rectilinear
catheterism was recognized. The straight catheter then having become a
capital instrument, we have no cause for astonishment at the importance which
is attached by some persons to its invention. On this point, as in almost
every other of the great operations in surgery, we have arrived at the reali-
zation of the fact only by degrees, and the real discovery will be found
separated from the period of its declaration by a very considerable lapse of
time. It may not be entirely proved that Albucasis, Sanctorius, or any other
old author had any idea of a straight instrument for entering the bladder;
and we may doubt perhaps whether the straight stems found by E. Clark in
the ruins of Herculaneum, or if those in the office of a surgeon at Portici,
ever were instruments of catheterism. It may be incorrect to say that Ranieau
proposed catheters perfectly straight, but it is at least undoubted that Lieu
taud did formerly promulgate the thought, and that the proposition has been
I
OPERATIVE SURGERY. 8S1
far from forgotten. It is in fact reproduced in the Elements of Surgery,
published in 1768, by M. Portal ; and afterwards in the Dictionary of Sur-
gery, edited by Louis. In 1795, Santarelli, a surgeon of Rome, returning to
its consideration, attempted to prove that the urethra has no curve in its pro-
static portion, and that it is easy to do away that which occurs beneath the
symphysis, by depressing the penis. Lassus made similar statements in his
lectures at the school of medicine, and M. Montagut confidently asserted
in 1810 that rectilinear catheterism is as easy as it is useful in a majority of
cases. Another French physician, M. Fournier of Lempdes, who paid much
attention to lithontriptic means in the year 1812, employed a straight instru-
ment. The well authenticated certificates collected in the book which he
has just published, leave no doubt upon the subject. The work of M.
Gruthuisen, published in 1813, at length revealed all its advantages ; so that,
even excluding the assertions of several army surgeons, MM. Larrey and
Ribes among others, w^ho state that they have often used straight catheters on
service, it would be quite impossible to claim for our own time entirely the
invention of catheterism with straight instruments, which was contended for
by M. Moulin, in his turn, as late as 1829.
In fact, custom and prejudice had opposed it; particularly in so much that
as a means of entering the bladder and giving exit to urine, a straight catheter
is incontestibly much less convenient than a curved one. It was necessary,
in order to allow this species of catheterism to take rank in practice, that it
' should be presented under some other point of view. Between the years
1815 and 1823, the want of some means of destroying calculi without resort-
ing to a sanguinary operation was felt more powerfully than ever, and several
surgeons engaged about the same time, in researches on this subject, in simi-
lar ways or by different modes. Upon these experiments the possibility of
passing the urethra with catheters, &c. not curved was anew proclaimed.
M. Amussat, though in order to induce conviction he laid a great stress upon
an anatomical error, succeeded at length in awakening the attention of sur-
geons to the subject. Whilst he was laboring vainly to demonstrate how
exceedingly mankind had been deceived as to the real course of the urethra,
MM. Leroy d'Etioles, and Civiale seized upon the practical inference, and
left M. Amussat to wrangle out the discussion in which he had engaged. It
does not appear, indeed, that until then they had thought of a straight sound
for fracturing the stone ; and the instruments of M. Leroy were still straight
at that time. The statements of Lieutaud, Sautarelli, Montagut, and the
labors of Gruthuisen, which would have been of such great service to them,
had evidently escaped their observation. We may then say with every confi-
dence that from this period only does lithotrity date.
Breaking up a stone is now practised in divers ways, so different that each
requires a succinct analysis. In one, that which was first practised on the
living subject, we are content to perforate the stone in several directions ;
then to break it into fragments, and to perforate or break each of these one after
the other, and extract them piecemeal, unless the bladder should itself expel
them along with the urine. In the other, simple perforation alone is not con-
sidered sufficient. The surgeon endeavors, by means of special lithotritic
instruments, to excavate the stone from centre to circumference, to reduce it
to a shell which is then reduced to fragments, and divided as above. In a
I
*T
822 NEW ELEMENTS OF
third method the instruments act from the circumference to the centre only,
and serve to pulverize by true concentric friction. A fourth way of acting
is that which aims at grinding or crushing the stone without previous perfo-
ration either from the centre to the circumference or from before back-
wards.
a. Perforation, pure and simple, which was by M. Civiale adopted from the
beginning, is the method which he still prefers. The instruments required
for it are, Ist, a large canula from two to four lines in diameter, from
nine to twelve inches, which serves in a measure as " chemise" or covering
to the other instruments; Sd, of a forceps called litholabe, intended to seize
and hold the stone; Sd, of a drill, either cylindrical, three or four pointed,
or else having a head, and of a trephine shape; 4th, of accessory articles,
such as a crank or winch, rings, chevalets, mandrel lathe or tour en Pair,
vices, &c. ; all of which serve to support the principal pieces from without,
and make them act inside of the bladder.
1st. The Chemise or outer canula is a part of eivery apparatus, and is found
in every procedure. When it has been introduced into the urethra it remains
in it, and serves to protect it. As it should be moulded upon this canal there
must be some of different sizes, of greater or less dimension, according to
the age and peculiar structure of the patient. It is requisite that with as thin
walls as possible it should combine great powers of resistance; at the vesical
end at least. Its outer extremity is usually fitted with a leather or cork box,
and cut quadrangularly for an inch or two so as to be seized by the vice or
lathe.
2d. The Litholabe is the part which has been most frequently varied, and
which also constitutes a portion in every procedure. Under this head it is
needless to speak of the first instrument by M. Civiale, which was analagous
to the quadruple vesical of Franco, nor of that which M. Leroy described in
1822, and which was composed of four watch springs which were capable of
forming when extended or relaxed a double loop crossed in the bladder, or
having joined to them as auxiliary a net so as to transform this cage into a
true sac ; or else in the place of springs, branches jointtd in the middle to
approach or diverge when their external portion is pushed or pulled upon ;
again, these branches may be of chain work, and by the aid of canula3 may
be made to form a cage of three or four branches around the stone by turning
one upon the other, particularly as these instruments have never been by any
one adopted, not even by the inventors themselves, whilst that of Mr. Lukens,
a mechanic in Philadelphia, is no better. M. Colombe has proposed one
composed of two concentric canals, each ending in two elastic branches,
united at their extremities, and which can be made to cross each other at a right
angle round the stone when seized. This instrument is evidently constructed
on a similar plan to that of the litholabe of Leroy or of Lukens, and will in
all probability suffer a like fate.
Thus far surgeons have generally resorted to the forceps properly so called.
This — which is a mere modification of the triple canula of Sanctorius or
Hildanus, of the ball extractor of A. Ferri, or Andrew de la Croix — has
also been that for whose invention most persons have advanced claims. M.
Leroy first made it known in April 1823 ; but it is asserted by M. Civiale,
who has given us a delineation of another in his work printed in June 1823,
OPERATIVE SURGERY. 823
that ever since the year 1820 he had been engaged in experiments with an
instrument constructed upon the principle of the Ferrian ball extractor.
Three elastic branches, which are curved crotchetwise and lap over so that
they may be closed and reduced to the dimensions of the principal stem when
withdrawn into their sheath, compose its vesical end. The other has a leather
box, but no vice such as the first canula has. The litholabe, such as I
have now described it, has not suited the wants of all lithotritists. Several
have endeavored especially to increase the number of branches. Some
have given it four. M. Amussat has proposed five. Meirieu divided
them into twelve. M. Tanchou prefers ten. That which M. Recamier has
proposed is composed of two canulae, which have each of them five, and
which by turning on one another soon form a forceps of five or of ten branches.
These different alterations have all been made with the view of holding the
stone, when once laid hold of, with greater firmness and security, and not to
let fall the principal fragments. The litholabe of Meirieu, successively per-
fected by MM. RecamJer and Tanchou, is distinguishable from every other
in having a hole in the free end of every branch to allow passage to a silk
string of great strength, which is intended to close them as does a purse string ;
and which passes through a particular groove in the canula to get outwards.
That of M. Recamier can moreover, by the rotation of its two canulae, pre-
sent a large opening on one of its sides to the calculus, and close afterwards
around the foreign body. In the apparatus of Meirieu and Tanchou we meet
with the same contrivance, but under another form ; that is to say, one branch
of the forceps remaining in the canula leaves a lateral aperture to receive the
stone, and then by pulling on the silken string may be thrust out level with the
others. Recently Dr. Ashmead, of the United States, has presented one
to this academy which has four divisions; three of which are pretty near each
other, and the fourth sensibly divergent. In this way the forceps leaves on
one side all necessary space for receiving large stones, and represents in
the other direction a firm grating which is to be turned downwards during the
grinding that no fragments of any size may escape. It would, no doubt, be
better if we could keep hold of a calculus until its entire destruction was
effected ; but all the instruments proposed effect this advantage at the sacri-
fice of a great many others. By multiplying branches you necessarily weaken
it much. As calculi are very far from having regular shapes, or from being
seized by their centres opposed to the centre of the forceps, it would be very
much to be apprehended that one of these many stems might have to bear
alone the whole effort, and consequently bend and break. This accident
would be rendered much less alarming by uniting the ends of the branches
by silk strings as in Meirieu's plan ; and the little cage offers a good deal of
regularity ; but may the string of silk not break ? may it not become entangled
in the stems of the instrument? and are we always certain to be able to make
it play freely ? Besides having once closed the litholabe, how are we to dis-
engage the stone from it if the bladder chance to empty itself and contract
violently? If the forceps of tiiree branches will not answer, that of Dr-
Ashmead, which, while it preserves more strength, allows of our obtaining a
tighter grating tlian a common forceps, can alone be substituted for it I think,
at least, in the procedure by simple perforation.
Lithotritors. — This is a stem or rod of steel, the vesical end of which is to
824 ' NEW ELEMENTS OF
act upon the stone, and which end alone can be susceptible of any material
modification. In M. Leroy's first apparatus this rod was cylindrical, and
terminated by points. In the instruments of M. Grnthuisen there is one tO be
found whose extremity has a head shaped like the crown of a trephine. This
Jatter form is preferred by M. Civiale. It follows therefore that his lithotri-
tor has to be introduced at the inner extremity of the forceps, and can only
be withdrawn along with the whole instrument; while the cylindrical drill
enters and is taken out at the outer end, on the other hand these drills with
heads make a much larger perforation evidently than the others; and M. Ci-
viale, to obtain a yet larger-opening, has had some made which were excentric,
that is to say, whose axis was outside that of the rod. With such an instru-
ment a stone may be perforated through and through ; but prudence generally
requires us not to go on quite to its farthest extremity, or at least not
to the level of the hooks of the forceps, for fear of wounding the bladder.
The advantages which it has are its great solidity, its acting powerfully and
surely, and that it endangers the occurrence of no serious accident. The
real objection which is made to it is that it can only make an opening of three
or four lines ; that it requires the position of the stone to be changed fre-
quently, and increases the number of sittings necessary if the stone be a
large one.
Development Drills. — Struck with the imperfection just mentioned, several
surgeons have attempted to remedy it. M. Leroy, one of the first, con-
structed Some drills, the "/raises" of which were more complicated, and
with opening or developing points {lances). Likewise a drill split at the end,
by which he could first pierce the hole, and then enlarge it, because when the
fraise was pushed out of the canula its two branches separated forcibly owing
to their natural elasticity. Another instrument of the same kind appeared
to him to be capable of answering the end still better. The two branches
diverged by the retraction of the head of the drill between them. At length
M. Leroy, still following up the same idea, employed successfully a cylin-
drical rod enclosing a double blade fraise, which when pressed upon issues
through two apertures placed near the extremity of the drill. He has besides in-
vented a simple bent file very much like that of M. Eldgerton ; also a double
one with two elastic branches, but none of these are worthy of being retained
in practice except his drill with two apertures enclosing the double fraise,
which has two branches equally elastic.
The double/m/ses of M. Civiale, which are separated by a transverse bar
or a simple head being drawn back through them by the power of a return
screw acting on the central stem, do not seem to me to deserve to be retained
either. It would appear that M. Heurteloup had been attentive to the im-
provement of which we are now speaking. In order to obtain an excavation
of eight or twelve lines in diameter, he employs a drill with a cylindrical
head and an aperture on one side, and which serves at first for piercing the stone.
When afterwards he wishes to begin to hollow out and excavate the stone so as
to reduce it to a mere shell, he pushes out the base of a denticulated shoulder
virgule which is contained in the crown of his drill, and which escaping
directly through the lateral aperture exceeds its circumference by one, two,
or three lines. This shoulder, though jointed, possesses great solidity, and
its inventor has frequently employed it in practice with the completest success.
OPERATIVE SURGERY. 825
b. Excavation. — ^For calculi of a still larger size M. Heurteloup uses what
he calls his '' forceps excavator" [evideur a forceps) ; that is to say, a cylin-
drtcal drill with a jointed fraise capable of lateral divergence so as to give
rise to an excavation of more than an inch in diameter; the first glance of
this instrument however forbids us to attach much confidence to it, and
shows that it can possess but little strength. M. Amussat has also attended
to excavation. His drill, which is constructed on the principle of one
by M. Leroy, is composed of a central crown and two lateral points. When
the stone has been pierced into with the closed instrument, the stem is drawn
back by a screw between the two /raises, which it separates in such a way as
to allow of a very considerable increase of the excavation. This instrument
has been successively modified by two distinguished cutlers, MM. Greling
and Charriere ; the one giving a firmer support to the two lateral wings ; the
other a more rapid divergence, and supplying them with a solid stay fixed to
the surfaces of the crown of the drill by two little perpendicular supports.
It is quite certain that, as constructed by M. Charriere, this drill seems capa-
ble of creating an excavation of from six to eight lines quite as easily as the
common /mise of M. Civiale will produce one of three or four.
The cylindrical drills with a virgule or shoulder which diverges three or
four lines from the axis of the principal rod, such as have been advocated by
MM. Tanchou and Pecchioli, seem to me to be much less convenient. I must
say the same of the triangular pointed, wind-mill armed counter sinks invented
by M.Pravaz; and of that which has been just recommended by M.Rigal de
Gaillac, with its sheathed drill. This surgeon, besides, has proposed to him-
self a plan other than that of any his predecessors. When the perforation is
eifected, a return screw draws back the fraise between the two blades which
makes the chemise or sheath, separates them, and fiistens them solidly against
the centre of the stone, which is as it were set into a handle made by the drill,
in such a way that it may be bruised against the inner surface of the litho-
labe. M. Rigal also thinks that by opening the forceps of his instrument the
stone may be shivered by excentric efforts. Herein he has followed in the
steps of M. Civiale, who propose! a similar measure after lithotomy, where a
stone is too large to be removed without danger ; of M. Leroy, who says the
same respecting calculi in the urethra, as had previously been suggested by
Fischer and some other authors in the last century but one. By way of recapitu-
lation, we may observe that it is doubtful whether lithotrity by excentric rup-
ture will ever become a method of general adoption, whether it be effected by
sheathed drills, by divergent blades, or by percussion on the free end of the
lithotritic instrument. As to excavation, the instrument which will do it
most safely and solidly, is the elastic double branch fraise of M. Leroy, as
perfected by M. Amussat ; although the mandrel {a virgule) by M. Heurteloup,
and the development forceps by M. Pecchioli, are calculated in many cases
advantageously to supersede it.
c. Concentric Friction. — Instead of opening the stone through its centre,
and excavating it from its interior outwardly, Meirieu has conceived the idea
of grinding it to powder by acting upon its surface and towards its central
portion with a cylindrical drill supplied with two shoulders, which develop
laterally, capable of being voluntarily widened, and of making a sort of
clover leaf with the stem. MM. Recamier and Tonchou have followed the
104
826 NEW ELEMENTS OF
same plan, and their efforts have had no other aim than to render its applica-
tion more easy by improvements either in the litholabe or the lithotritor. It
is not possible to deny the greater rapidity of this sort of trituration ; that by
means of it we may in fact pulverise a large stone at a single sitting ; that it
guards against all risk of parcelling the stone into fragments, or that it allows
us to keep it fast until all is finished without letting it go. But the drills and
fraises which it is necessary to use are unavoidably weak and may bend and
break. The separation from each other of the virgules, leads to the apprehen-
sion of their becoming entangled with the branches of the forceps if it is
necessary to bring them too near the sheath. We have besides all those in-
conveniences of which I spoke when on the subject of the litholabe with
many branches connected by silken strings. The essays of Meirieu, and
those of M. Recamier have been performed only on the dead body. M. Ton-
chou on the contrary has gone farther than this. He has just announced to
the institute that he had been enabled by means of his instrument to grind to
powder at one sitting a stone of some size, in a patient who is now perfectly
cured of the calculous affection. He also last year performed in my presence
several attempts' upon an adult man whom I sent to him for the purpose.
The stone could not be seized, however, and I thought it proper to cut him for
it. We then ascertained that the foreign body was of entirely too large a size for
lithotrity by any method to have succeeded. It would be unjust therefore to
refuse to M.Tanchou's apparatus the possibility of being applied with advan-
tage. There is something at first sight very ingenious, nay, very plausible in
M. Rigal's plan of concentric friction by means of the inner surface of the
litholabe, against which the stone socketed by the sheathed drill is made to
turn ; but the slightest reflection wull serve to show that is an idea which must
remain unapplied.
d. Crushing the Stone is one of the methods to w^hich the ancients paid
particular attention. Accordingly it is crushing and not friction which we
find mentioned by Acaravius, and which F. Hildanus and others per-
formed. M. Amussat likewise operated by crushing in 1822. This method of
treating calculi, for awhile forgotten seems now likely to dispute the palm
with lithotrity properly so called. Some among those who propose it, adopt it
only as an accessory method, and for small stones, or the fragments which
follow perforation or excavation ; others again, seek to extend its fame as a
generally applicable method. In the first case it has usually been combined
with the other methods. M. Civiale, when he finds that the stone he has
seized is only three or four lines in size, for instance, immediately compresses
it with great force between the branches of his litholabe, and crushes it at
once by pushing the head of the lithotritor with the palm of the right hand.
He does the same with all fragments of any size, or too considerable to be
drawn on trial through the urethra. M. Civiale had also contrived a forceps
with two grasps, capable of sliding over each other and crushing small stones
by a backward and forward motion, very like that of M. Amussat. Tliis
instrument has been modified by M. Rigal, who made it act through the medium
of a return screw, dispensing with the motion backward and forwards. M.
Columbat thought it might more easily be managed, by adding to it flyers to
make it move, and by fastening a small chain to the end of each grasp,
Ui draw it out without danger if it should chance to give way and break.
The forceps constructed with this view, which has attracted most notice, is
OPERATIVE SURGERY. t^9lf
tliat of M. Heurteloup, delineated in his book under the name of ** brise-
coque" (shell-breaker). The two grasps rub on each other, and are enabled
to re-enter the external canula by means of spring- work, which they do with
such power as to shiver into splinters the hardest stones, and those which
offer the greatest resistance. I have seen this surgeon use it at the school of
Perfectionnement and cure two patients, each at a single sitting. It is an in-
strument whose compressing force is perfectly incalculable. It is much to be
regretted that it is able only to undergo very trifling divergence, and can
therefore include small stones merely. A forceps was constructed by M,
Rigaud, in 1829, while yet engaged in the study of medicine, upon nearly the
satne principles, but instead of two grasps having three. It is a sort of grinder
which can lay hold of stones of an inch in diameter, or more even, just in
the way that tiie common litholabe does. Spring-work machinery of a very
complicated kind in the handle, enables the three branches to move and to
exercise friction on three parts of the stone at once, which reduces it to a
fine powder, and allows of its entire destruction before it is let go. It is a
stone, or shell-breaker, which is not so powerful as that of M. Heurteloup,
but which has the superior advantage of destroying the stone by friction,
instead of shivering it into fragments. Still more recently, a clever cutler,
Mr. Sirhenry, has constructed another forceps equally capable of crushing
the stone. It is of three branches, which have no hooks, and have a denticu-
lated crista on their inner surface, which is applied on the foreign body. It
is introduced into the bladder like the common litholabe. When the stone is
fairly laid hold of, the branches are drawn back into the sheath by a return
screw, which acts with such prodigious power that silicious stones and
pebbles cannot resist it. In an attempt which was made with it some time
since at the Hotel Dieu, one of its branches broke ; and this is indeed the
fear which a view of it at first inspires ; but to this Mr. Sirhenry replies, that
the instrument used was an extremely weak one, never intended for such
large stones, and that he had warned them of the possibility of the accident.
Certainly, that one which he showed me, and before which the hardest calculi
gave way, was possessed of such strength that it appeared really impossible
to break it.
Some persons have urged as an objection to it, that the bladder is liable to
be injured by the fragments of stone which are scattered by the instrument.
This danger is clearly chimerical. No pain resulted when a stone was thus
shivered between my hands, and as we act in the bladder filled with liquid
there is nothing to be feared in this quarter. Surely the brise coque of M.
Heurteloup, and some other instruments of which we have yet to speak,
should possess similar inconveniences which nevertheless have not interfered
with their application on the living man.
e. Of the Four Ways of Breaking Stones. — No particular one deserves adop-
tion to the exclusion of the others, nor does any deserve absolute proscription.
Perforation of a stone of five or six lines is very advantageously combined
with crushing ; for after the fraise has made an opening, say for example of
four lines, we may, after having drawn it near the sheatli, pull the litholabe
forcibly backwards, and afterwards use it as a *' hrise coque.''^ Instead of this
procedure we may, if the exploratory means used have demonstrated almost
certainly that the stone is a small one, employ the grinder of M. Heurteloup,
■^
82fe
NEW ELEMENTS OF
or some one either of the spring-work flyer, " volaintp or rectum-screw forceps
previously described. When the stone exceeds ten lines or one inch, per-
foration, excavation, and then crushing are successively proper.. To conclude,
to me it appears incontestible, that with Rigaud's forceps we should succeed
without much difficulty in breaking calculi of from eight to twelve lines in
diameter ; and the same I think might be done more easily still by that of
Mr. Sirhenry.
One remark which must not be allowed to escape observation is, that with
crushing forceps the operation is made wonderfully more simple, as drills,
strawberry-shaped files [/raises), supports, &c. become all useless. So that
if their employment ever becomes general, it will be a very certain means of
making lithotrity popular,
§ 2. Curvilinear Method.
It is a singular thing that bruising of calculi could never be effected until
the possibility of passing straight instruments into the bladder was demon-
strated. To render the proofs of this possibility incontestible, serious
anatomical errors have been maintained ; and now when no one entertains a
doubt on either of these subjects, everyone perceives that curved instruments
are perfectly able to fulfill the end which had been aimed at for so long a time.
The file-mandrel or stylet (mandrin a lime), used by colonel Martin, was
carried through a curved sound. M. Eldgerton's instrument had the natural
curvature of all catheters, and so had the first lithoprionic instrument in-
vented by M. Leroy. The most difficult point in this system was to turn
the lithotritic instrument on its own axis. However, M. Pravaz triumphed
over this obstacle, and in 1828 succeeded in rendering the motions of a drill,
strawberry-shaped file (/raise) quite as easy in a curved as in a straight
canula. To accomplish this he transformed the lower fourth of his perforator
into an articulated stem, into a small chain not less solid however than
cylindrical rods made of a single piece. Still his instrument which had an
arch of a long circle, did not possess all the advantages which it was
intended to have : and the inventor finished by giving it a curve like that
of ordinary catheters ; that is including in it only the vesical fourth. M.
Pravaz failed with this instrument in an application of it at one of the
hospitals in Paris, on the living subject. This want of success might be
owing however to a want of practice, to the indocility of the patient who was
but a child, and particularly to the peculiar situation of the stone. It would
be difficult to assert that his apparatus, which in no way but in the direction
of its principal pieces differs from any other, should not be capable of pro-
ducing similar effects. I should even say that it must certainly be much more
easy of introduction, and much less fatiguing to the urethra. M. Leroy
showed one quite similar as to the disposition of the chain and drill which
was curved like a common sound ; and which he had yet further to modify in
order to adapt it for application to a patient whom it was impossible to sound
with straight instruments. It had this peculiarity, the third branch of the
litholabe was fixed, and a component part of the conducting canula. The
instrument of M. Pravaz, and that of M. Leroy, admit of perforation,
excavation, and friction, like straight instruments ; but their shape is
OPERATIVE SURGERY.
still better adapted to crushing. Mr. Welsh of London, and M. Rigal, have
given a slight curve to their friction or spring-work forceps, and M . Jacobson
constructed a species of nipper which is equally curved. This latter in-
strument is composed of an outer sheath or canula like all the rest — then
of a cylindrical steel stem which completely fills it, and extends it for three
inches towards the bladder — this stem is in two halves, jointed at top, placed
the one above, the other beneath, in such a way as that the lower one being
pushed forward separates from the upper which is fixed and forms, by
means of two or three hinge-like divisions, a loop capable of embracing a stone
of twelve, fifteen, or eighteen lines. A return screw at its free extremity
allows it to be restored to its primitive position. As it was proposed by
the Danish surgeon, it had but two divisions, " brisures,^^ in its inferior branch.
M. Dupuytren thought that it would be better to give it three, to make the
loop rounder and more regular. It is introduced closed into the bladder.
Then by pushing upon its outer extremity the inferior half separates a little.
This makes a space between it and the other half, which space may be en-
larged ad libittiin, and the extent of which is pointed out by figures on
the outside of the nut or box. In this void or loop the stone is engaged.
When accurately seized, we act on the return screw, as if to isolate
and close the instrument by the approximation of its two branches.
Nothing can be more simple than such mechanism ; nor need any thing be
easier than the operation itself. Here we have not even to fear fracturing
the instrument, for its articuiations will always allow us to withdraw the
fragments without danger. All that can be said against it is that having only
two branches it cannot so easily as the others lay hold of the stone, and that
if we confine ourselves to crushing it we are obliged to reseize every separate
piece. I must add to this, that the detritus of stone which sometimes remain
sticking to the inner surface of each grasp are calculated to render their
approximation very difficult. M. Dupuytren who used it on a patient was
much pleased with it, and four or five sittings were sufficient to enable him
completely to destroy a voluminous stone ; so that, either as it now is, or after
it shall have received such modifications as I conceive it to be susceptible
of, this instrument may yet make eccentric friction, either by perforation or
excavation much less rare, and in a great many cases do away with the ne-
cessity of straight instruments. Adopting the curved lithotritor, M. Segalas
also thought fit to modify it in the case of a patient who could not bear the
introduction of straight instruments. The improvements by this surgeon
chiefly relate to the rod of the perforator, which after his plan, instead of being
made with a jointed chain, is made of metallic wires collected into a fasciculus
or bundle ; and also the means of pulling out the fragments of the litholabe
if it happens to break in the bladder, without danger; in all which I see but
changes of trifling importance and useless complexity.
M. Heurteloup, returning to the idea of themonkof Citeaux, has proposed a
curved instrument which opens after the manner of a shoemaker's foot-rule or
measure; and which after having securely grasped or fastened the stone
between its blades, allows it to be broken and reduced to fragments by
means of blows inflicted with a hammer on the end of its upper or movable
branch.
A
856 NEW ELEMENTS OF
This system, which the author calls lithotrity by percussion, has already
been several times practised by him with entire success in London : and the
attempts which he has made on the dead body in Paris prove effectually that
stones may be destroyed by it with more force and quickness than by any
other method. Yet as it requires instruments of immense calibre and great
strength to avoid breaking inside of the bladder, I am doubtful whether this
new method will ever obtain the currency which M. Heurteloup seems to
anticipate.
§ 3. Accessory Apparatus,
Whatever be the lithotritic system we have chosen to adopt, the means by
which it is set in operation deserves the attentive consideration of the surgeon.
The mechanism of stone-breakers (hrist-pierres), of shell-breakers [brise-
coques), of saxifrages and grinders {grugeoirs), having throughout been brought
forward in the system of return screws, double levers, spring-work {encUque-
tage), or wheel and catch work (engrenage), makes a part of the principal in-
strument, and requires no separate description. Not so however with
breaking, properly so called, effected either by perforation, excavation, or
concentric pulverization. Two orders of springs then become indispensably
necessary; 1st, to keep the litholabe firmly together; 2d, to make the lilho-
tritor act.
Under the first intention, the chevalet (easel) a sort of lathe, ''tour en P air, ^^
proposed first by M. Leroy, after Ducamp, and slightly altered by MM.
Civiale, Rigal, &c. has generally been adopted. Some persons however have
preferred to substitute an ebony vice with one or two handles ; but the chevalet
is evidently better. Others have exercised their ingenuity in fixing the
instruments as well as the patient. Hence the beds with or without support,
contrived by MM. Leroy, Heurteloup, Tanchou, Rigal, &c.; contrivances
perfectly useless evidently, and which M. Civiale has always been able to
dispense with. The bare idea of metallic supports, to remain immovable
upon the foot of the operating table as in that of M. Charriere, or the me-
chanical bed like that of M. Heurteloup is alarming. Let us fancy to
ourselves in fact some sort of forceps and lithotritor working in the bladder
of a living; man, whilst an inflexible bar of iron planted upon the table fastens
them without, and we shall then see whether the least disorderly or unex-
pected motion of the patient is not of a nature to make us tremble for the
consequences. However ingeniously they be contrived, the use of this arti-
ficial force must be abandoned, and their place supplied by able assistants
or the hand of the surgeon himself. By pressing with his chest against the
lithotritor, through the intermedium of a crescent-shape handle, in such a
way as to hold the litholabe with his left hand, whilst with the right he turns
the drill with a wooden instrument like a wimble. M. Amussat avoids all
these dangers ; but he acts with less power than by employing a lathe and
tires himself much more; so that all things considered the easel or chevalet
does best after all.
Tl\ere are two powers to be directed in the action of a drill ; that which
presses upon its outer extremity to keep it in contact with the stone, and
that which obliges it to turn upon its axis. Those persons who supposed that
OPERATIVE SURGERY. 8SI
they could find the former in the thumb, the forepart of the chest, or the knee,
have evidently deceived themselves; unless they could discover a system
which is a better combination than that of the wheels, wimbles, and cranks
hitherto invented. The spring en boudin, enclosed in the movable "poupee^^
(puppet) of the lathe certainly is far from satisfying our wants. Still as long
as the drill-bow shall continue to be preferred as the rotary agent, I see
nothing by which it can be advantageously replaced. Rings, flyers, handles,
which would seem at first sight sufficient for the power of rotation, have not an
extended action, and neither sufficiently favor the forces set in play, and their
movements are of little service. The catch -wheels placed beneath, as in M.
Leroy's contrivance, and as are again proposed by M. Rigal, or on the side
as in M. Pravaz's apparatus, whether they act upon a pinion placed parallel
to the axis of the litholabe, or whether they catch in an indented pinion, coni-
cal and circular, give to the drill as rapid a motion as is required ; but the
means of compressing its extremity with sufficient force at the same time still
remains to be discovered. The mechanism of the drill-bow is the same in
lithotrity as in any of the mechanical arts in which it is employed. Until
wheels can be substituted for it, prudence requires that its use be continued,
and the good end which it has already answered after all allows us to repose
more confidence in its use than in that of any other instrument which tends
towards the attainment of the same object.
*^rt, 4. — Method of Operation.
Before we proceed to perform lithotrity, there are some special precautions
to be observed. Supposing the urethra to have been diseased, its natural
dimensions must first be restored as well as its original dilatability. Even
though this canal should be wide enough to allow the instruments to pass, it
must nevertheless be subjected for some days to the action of bougies or
flexible sounds to dull its sensibility, and accustom it to the prescence of
foreign bodies. With this view it is often useful for the same reason to
inject the bladder several times to diminish its irritability, that it may the
more readily allow itself to be distended at the time of the operation. Though
not indispensable these are preparatory steps, which except in a very few
persons should not be neglected.
a. Position of the Patient. — lii civil practice it answers very well to let
the patient lie on his back on the edge of his bed, his pelvis supported by a
rather hard cushion, his feet resting upon two stools, and the head slightly
bent upon the chest. In one's own house, or in a public institution,, he would
be placed on a narrow bed of a convenient height, so that his legs might pro-
ject beyond the foot of it, and be sustained as in the preceding case. In this
position he neither requires to be tied nor bound ; the posterior wall of the
bladder becoming the lowermost it allows the stone to go further from the
urethra; and thus, as it were, to off'er itself to the litholabe. It is easy to
alter it according to necessity, either by giving the pelvis a loftier elevation,
where the stone has a tendency to stay in the bas-fond or by diminishing
the thickness of the cushion when the contrary is feared ; a resource which
we have not to the same degree in lithotritic beds or tables.
b. Injections, — A first stage of the operations consists in filling the blad-
832 NEW ELEMENTS OF
der with warm water or some emollient decoction. But for this the lithotri-
tor and litholabe could not play freely ; the stone could not always be seized ;
and the organ would be pinched almost infallibly. It is done with a common
catheter and a hydrocele syringe much more surely than by bladders, or
india rubber bottles, or by the sheath, or canula of the litholabe. The silver
catheter when introduced serves anew for feeling the presence of the stone.
An assistant takes hold of it for the surgeon to adapt the pipe of the syringe,
and send on the liquid. When eight or twelve ounces are thrown in, or bet-
ter still when the patient expresses a strong wish to urinate, we withdraw
the catheter and instantly substitute the lithotritic apparatus before there has
been time for the injection to be returned.
c. Introduction of the Forceps. — The drill, slipped into the canula of the
forceps, and fitted with its box to receive the bow; the litholabe in turn
introduced into the common sheath and furnished with a box at its outer
extremity, so that its branches closing exactly upon the grooves in the
head of the lithotritor, which represent an olive made smooth with some
tallow, are then passed, united into one instrument, like a catheter into
the urethra. To do this, the operator standing on the right side of the
patient lays hold of the penis with his left hand, as in performing the com-
mon introduction of a catheter ; raises it a little ; presents perpendicularly
to it with the right hand the instrument well oiled or greased ; enters the
meatus urinarius slowly, by gentle rotatary movements ; speedily arrives at
the bulb ; stops for a second ; powerfully, yet gently depresses his hand to
get underneath the symphysis, through the membranous and prostatic portions
of the urethra; and so clears the neck of the bladder.
d. Finding the Stone. — Before the litholabe is opened, he is to find the
stone, by feeling about backwards and forwards with the olive- shaped extre-
mity of the still closed metallic instrument ; 1st, from before backwards,
upon the median part of the bas-fond and posterior wall of the organ ; 2d,
from behind forwards, as if to complete the circle, returning by the right or
by the left side ; 3d, a second time from before backwards, returning by the
side opposite to that last passed over, coming back to the centre into which
the stone may have fallen, and then transversely, so as Dr. Ashmead says
to leave no portion of the floor of the bladder untouched. If we can find
nothing after this minute search, it is better to postpone the operation than
obstinately persist in continuing it. Still it should not be abandoned until
after the position of the patient had been varied in every way, and we
are perfectly sure that no natural excavation or depression has been over-
looked.
e. Opening the Forceps. — When he has discovered and approached the
situation of the stone, the operator takes and holds firmly the end of the
litholabe in his right hand, and uses his left hand to draw towards him the
outer canula, as if he was going to take it out of the urethra, and thus allows
the forceps to open by removing the restraints upon the natural elasticity of
the branches. The bladder runs much less risk in this way than if he slipped
the litholabe forward without disarranging its sheath, with a view to save the
urethra, the entrance to which moreover is perfectly filled up by the neck of
the triploid as it opens in the urinary sac.
f. To find the Stone again and grasp it is often much more difiicult than
■w
OPERATIVE SURGERY.
is supposed; especially, as Dr. Ashmead says, because feeling it is not
always sufficient to point out its exact situation. This search for it, now
requires the utmost care. The difficulty is to say whether we are touching
it; 1st, with the convexity of one or both the lower crotchets; 2d, by the
middle, inner, or outer part of one of the branches, and if so, whether the
right branch or the left; 3d, by the inferior surface of these same branches
near the prostate. The following rules on this subject should not be
neglected.
If, in balancing the instrument it is perceived to fall upon the foreign body
with the sensation of a double clash, the stone is situated beneath the two
branches and behind the prostate.
If one branch descends lower than the other when turned upon its axis,
and but one collision occurs, it will be found on the highest side.
If it lies forwards, and the two hooks alternately and not simultaneously
pushed on equally detect it, it may be said to correspond to the space between
them.
If one only strikes upon it, it must be upon one side. To detect whether it
be the right or the left, we are to keep one crotchet motionless, whilst the other
is gently made to advance. Let us, instead of this, suppose it to be outside
of the left branch; then taking the other for the fulcrum, it is to be raised
and lowered by rotatory movements which describe the arc of a circle, and
will then not fail soon to detect it, whilst the same motions performed on the
opposite side will cause nothing to be perceived.
A transverse limited movement, first to the right and then to the left, will
in like manner inform us if the stone is within the litholabe, nearer to one
branch than the other, or in the centre. These different manipulations, done
with a little address, will not leave us long in doubt as to its real situation
if the surgeon has taken the precaution to place inferiorly two branches on
the same level.
Such being the state of things, it cannot be very difficult to include the stone
in the area of the instrument, nor consequently to grasp it. Not to derange
the relative situation of the diiferent objects, the surgeon takes the free end of
the forceps and raises it a little with the right hand, so that its branches may
be kept in contact with the floor of the bladder; after which, taking hold of
its leather box with the left hand, the canula or chemise is pushed down upon
it. It is also advantageous, previously, to draw the drill backwards and
forwards in the tube, and between the divisions of the litholabe, until the
fraise has absolutely touched the stone. By an effort in a contrary direction,
on the sheath and on the stone, the concretion is finally fastened, and then
nothing remains but to attack it with the lithotritor.
g. Applying the Lathe and the Brill-bow. — This is now the time for apply-
ing the supports and agents of motion. A pressure screw first prevents the
two closed instruments from reopening. A nwrtice which there is on the
top of the lathe then embraces, seizing it underneath the quadrilateral extre-
mity of the sheath in front of the box, which extremity is furnished with
lateral edges, and a pressure screw fastens them at once in this position.
The little cup of the spiral spring, supported by the puppet of the lathe is
then applied to the tail of the drill. The puppet is pushed forward with a
violence proportioned to that action which we intend to exercise upon the
105
834 NEW ELEMENTS OF ^^
drill and on the stone. It is stopped by a turn of the screw. If the pres-
sure of the spring appears too great, a fourth screw enables us to suspend
or continue it at pleasure. The apparatus is then ready. An assistant
turned towards the pelvis, and standing on the right side or between the legs
of the patient, takes charge of it, and seizes it by the handle in the right hand,
and near the curved portion with his left. The operator takes the loosened
cord of the drill-bow, passes it around the box which has been previously
placed upon the drill, and brings back the buckle to be attached to the end
of the elastic arch, from which it had been for a moment separated ; always
recollecting that the string tliough it should be delicate should also possess
great strength, and work with as little friction as possible.
h. Friction, — This being done, the surgeon still standing on the right side,
holds the instrument firmly with his left hand between the penis and the
head of the chevalet or easel ; whilst with his right he makes the drill-bow
act, carefully inclining the effort forward, and combining pressure against the
stone with rotation unless the spring seems to be sufficient. The drill box
has moreover been arranged in such a way as to strike against the drawing
box of the litholabe, before the head of the drill can reach the vesical extre-
mity, and go beyond the circle of the forceps.
Having finished this preliminary perforation, we are to draw back the
puppet of the lathe so as to bring back the drill towards ourselves. If the
stone is friable and small, we try to break it before letting it go, by acting
powerfully on the two cork boxes in an opposite direction. If not, we open
the forceps moderately, and then by striking gentle blows on the free end
we try to move the stone and to change its position ; which change we may
effect by the assistance of the drill directed by the right hand. If nothing
will succeed in effecting it, we must wholly abandon the stone, and seize it
again precisely as if it had escaped by accident from the operator. For fear
it may not present by exactly the same diameters, which is extremely rare, we
push the drill hard against it, so as to move it again if it falls into the same
hole ; and not set it again in motion with the bow, except so long as it meets
with a solid portion of substance to destroy.
The use of development drills, of strawberry-shaped files with shoulders
(/raises a virgu/e), and files with single or double wings, is subjected to simi-
lar rules, whether originally made use of, or only after the first perforation.
In the first case, we must so separate them as that they will turn freely
behind the stone, without touching the inner surface of the branches of the
litholabe, and so that the central may serve as the axis to the lateral wings,
whilst they are acting on the stone. In the second case we open them only
by degrees, and even within the first perforation. The name of " echoppeur,^^
graver or exca^vator, then really becomes applicable to them, since they serve
to reduce the same to a shell, and to hollow it out into a conoidal cavity whose
summit removes backwards. ^ Spherical stones of rather large size, taken
centre for centre, are best adapted to it; those which are elongate, which are
grasped laterally or by some projecting part, and which leave a void on one
side between the branches of the forceps, render their action difficult and
sometimes dangerous, owing to the unequal resistance which they meet with
in turning. M. Tanchou's apparatus, though more ingenious, is not wholly
OPERATIVE SURGERY. 835
free from this inconvenience, and I think it in such cases most prudent to
confine oneself to simple friction and crushing combined. When the stone is
entirely powdered, or the patient is too much fatigued, say in five, eight, ten,
and at the utmost twelve minutes, the sitting should be completed. We take
oft' the bow ; loosen all the screws to take oft* the chevalet or easel, and with-
draw the drill as we keep closing the forceps. When a fragment adheres to
their branches, it is, if not too large, drawn out with the remainder of the
instrument; but if there be any cause for fearing its action on the urethra,
it is better to let it go, and allow it to fall into the bladder again, by pushing
it back with the lithotritor. The remains of the injection and the urine,
which the patient is usually very anxious to void directly afterwards, almost
always bring with them pieces of calculi, and a greater or less quantity of
powder, resulting from the grinding, which are the best proof, so far as the
patient is concerned, of the success of this operation. We advise a bath on
the same evening or immediately. In general, all the treatment which the
case requires is that which is called for by states of convalescence of any
kind, or by invalids usually. At the end of two, three, four, or five days,
according to the agitation of system produced by the first attempt, we begin
again, and again observe the same precautions ; and so on until no further
vestige of stone exists in the urinary bladder. One or two examinations
with the common sound, at intervals of some days, are necessary to produce
certain conviction on this point, and ought upon no pretence whatever to be
omitted.
£rt 5. — Remarks on certain Points in the Method of Operation, and on the
Accidents which occur in Lithotrity.
In spite of the leather boxes, and the accuracy with which the three princi-
pal pieces of the apparatus fit into one another, it sometimes happens that the
injection escapes between them, or else between the outer canulaand the walls
of the urethra. A *' tubulure,^^ or neck, placed upon the back of the chemise
or sheath, and made to communicate with the bladder hy a groove hollowed
out upon the external face of the litholabe, is now added to almost every new
instrument with a view to remedy this inconvenience. The pipe of a syringe
may in fact be added to it, so as to make a catheter of it, and renew the in-
jection; but the irritability of the organ soon brings matters to the same point,
though happily it is not often entirely emptied.
Lithotrity before puberty is not so easy as it is in the adult. 1st. Because
of the imperfect development of the genital organs, the narrowness of the
urethra, the unmanageableness of the patients, and the exquisite sensibility of
the parts. The instruments should not be more than two lines or two and a
half in diameter, which sensibly lessens their power, whilst at a later period
of life this may be extended to four lines, although those of three lines or three
lines and a half are generally sufficient.
They are still less adapted to early infancy for the same reasons, and more-
over because the bladder, rising too high in the pelvis, augments in propor-
tion the curve of the hinder third of the urethra, and thirdly, because cutting
at this period of life oft*ers a great chance of success.
The prostate gland in some persons makes its application difficult, owing to
836 KEW ELEMENTS OF
the crowding back of the urethra behind the symphysis. In such cases, curved
instruments are in a measure necessary. M. Leroy struck with this want,
and desirous of doing away with its importance, and having oftentimes expe-
rienced the danger and impossibility of straight instruments, has proposed a
measure, in appearance a very simple one, which he calls redresseur, straight-
ener of the urethra; composed of a gumelastic catheter introduced crooked,
and when in made straight again by a straight mandrin which is pushed
slowly into it from before backwards by a screw. This instrument resem-
bling tliat which M. Rigal has contrived in the same view, and which
might well be superseded, as M. Pravaz remarks, by the cylinder of the litho-
tritor, carried with the hand, by spiral movements through a large flexible
sound, open at both ends, endangers the occurrence of serious accidents, such
as contusing the verumontanum, and tearing the urethra by means of the screw
or the nut of which we cannot calculate the power ; and also because the head
of the mandrin or stylet makes its way by striking against every point of the
inferior wall of the canal. That of M. Tanchou, would be decidedly prefer-
able, if straightening the urethra were a precaution really necessary to be
taken in such cases, as it is formed on its vesical third of a series of
small jointed pieces, which allow of its being introduced curved, and straight-
♦Mied when in, without the slightest friction. But if rectilinear catheterism is
not practicable, it is according to my view of the case much better to resort to
curved instruments, or even to lithotomy, than to rely on such means.
Extreme development of the prostate brings with it another inconvenience ;
it changes the bas-fond or trigone of the bladder sometimes into a deep exca-
vation, in which the stone is not always easily seized. The fingers of the
surgeon himself or his assistant introduced into the rectum, would I think be
preferable for raising and offering it to the claws of the litholabe to the little
bag invented by M. Tanchou or any species of tampon whatever, which could
be slipped up above the anus.
Lithotrity upon females is infinitely easier than in man, and almost without
danger. In them the canal being wide, distensible, short, and not curved, free
from prostate gland or seminal orifices, adapts itself admirably to the pas-
sing in of the instruments necessary, neither does it require as entire a pulve-
rization of the calculus. The only thing is that they have somewhat more diffi-
culty in retaining the injections, less indispensable however in a naturally
large bladder, supple, and so to speak, beneath the eye ; so much so, that in a
very few sittings a little girl of three years old was relieved of a large calculus,
notwithstanding that no liquid could be retained in the unnary reservoir.
Curved instruments, either those of Pravaz, Pamard, or Leroy, being intended
all of them for the same species of friction as that apparatus whose application
I have described, demand no particular detail of their method of operation.
The principal advantage they possess is that of fatiguing the urethra less,
causing less pain consequently, and of penetrating into the bladder more freely.
As on the other hand they are less convenient than the others for sounding the
organ, finding and seizing the stone, it is useless to attempt their use in females.
It may indeed be laid down as a principle, that, cseteris paribus^ straight instru-
ments are best suited for performing lithotrity by perforation, excavation, or
concentric friction ; whilst curved instruments answer better for crushing the
stone.
OPERATIVE SURGERY. 837
If the " grinder" [grugcoir) of M. Rigaud were curved, and if it were pos-
sible to lessen its size a little without decreasing its strength, it would deserve
frequently to be employed, and would be equal to the task of crushing any
stone not bigger than a nut. It is introduced in the same way that all other
instruments are. To open it, it is held towards the urethra by the left hand,
whilst the right acts on its handle by an effort which displaces the screw and
nuts. When it is ascertained that the stone is between the claws, it is closed
by an opposite effort, after which a see-saw motion and circumduction of the wrist
suffice to set in action the friction of the grasps upon the foreign body. The
shell breaker of M. Heurteloup, whose motions are very much the same, requires
pretty nearly the same management, except that the spring-work in it compels
it to re-enter its sheath at the same time with some violence ; thus crushing the
stone rather than grinding it. Its action indeed is more rapid, but is attended
witli tlie creation of splinters and fragments which have afterwards to be seized ;
whilst that of M. Rigaud cannot let go its hold until the last fragment of stone
it contains is reduced to a fine powder.
Mr. Jacobson's instrument being one of the easiest to manage will probably
be oftenest employed. None less exposes the bladder to injury. A mere
jointed loop, having neither hooks nor free points, it is almost impossible
that it should either pinch or pierce the walls of the organ ; so that strictly
speaking, it might be used without premising an injection. Its curve renders
its introduction as easy as that of a common sound. The way to open it is
very easy. The nut being brought back to the end of the screw we apply the
palm of the right hand on this end and push. The jointed branch of the forceps
opens forthwith in the bladder, as if to form the circle of a rocket or battle-
dore, rather irregular, owing to the dorsal concavity preserved by the other
branch. We proceed to search for the stone according to the rules always
given. When the calculus is entirely encircled by the metallic loop we
pull upon the screw, first with our hand as if we were closing a litholabe, and
then with the screw nut, which becomes in this case a return screw, which,
causing the two halves of the stone breaker to act like two large files rubbing
upon the stone in opposite directions, concentrates its whole action upon the
latter, and scarce can fail of crushing it. The numerous fragments which
follow it are submitted to a similar treatment and search. The surgeon needs
no assistant, and the patient feels but little Hitigue, nor does any thing prevent
the sittings from recurring at brief intervals. To conclude, the position is
the sanTe as for catheterism in general. It is only to be regretted that so many
advantages should be counterbalanced by a greater difficulty in finding and
seizing stones of small size : of being certain that we hold them in the loop of
the forceps, and by the impossibility of extracting with it any of the frag-
ments.
To accomplish the extracting of fragments, M. Heurteloup employs a
large sound, either crooked or straight, terminated at its vesical extremity by a
sort of thimble, called the magazine, which may be unscrewed at pleasure.
Laterally, and at about an inch from the summit, are two laro;e apertures front-
ing each other. The other end has its cork box, a stop cock for injecting,
and rings that it may be held by the fingers. The liquids introduced with
its assistance itito the bladder, bring with them, as they flow out again through
the apertures all such fragments of stone as are capable of entering and
838 NEW ELEMENTS OF
passing through them. Those which are too large for this are stopped at the
orifices. The inventor then uses a jointed, flexible stylet, like the lithotritor
of M. Pravaz, to break or crush the point which projects inwardly into the
magazine, and press it to the bottom, whilst the remaining portion falls back
into the bladder. When from more or less frequent repetition of this
manoeuvre the magazine becomes filled, the instrument is withdrawn for it
to be unscrewed and emptied, and is then reintroduced if it is thought advi-
sable to begin over again. M. Leroy conceives that this end may be better
accomplished by an instrument of the same kind, but in which the central
stem may act equally by pressure as by rotation. Without absolutely reject-
ing the assistance of similar contrivances, we are nevertheless obliged to con-
fess that the probable advantages to be derived from them, are not evident
enouL^h for practitioners hastily to adopt them, or to supersede by them, or
add them to other instruments of more acknowledged excellence.
Occidents. — Those which follow lithotrity, though seldom of a fatal
nature, are varied and numerous. The pain which naturally attends the
operation is sometimes excessively acute. As it depends more particularly
upon the traction of straight instruments upon the sub-pubic portion of the
urethra, it is to be hoped that the use of curved instruments will diminish its
severity. Every sitting is succeeded in a great many patients by a paroxysm
of fever, more or less violent, characterized by the same phenomena as an
intermittent. This is an occurrence to which even simple catheterism gives
rise, and obliges frequently to prolong the interval between the sittings. In
many cases we shall notice engorgement of the spermatic cord, epididimus,
and even testicle itself; which is explained to be owing to friction and con-
tusion sustained by the verumontanum and ejaculatory canal. Tears or
rents of the urethra, urinary infiltrations, abscess of the perineum and
scrotum, though less common, have nevertheless occurred. The chief
inconvenience of these events is that they oblige us to defer to a later
period, the date of the next operation. It is, however, but just to say that
one of the persons lithotritized in my presence by M. Civiale, was
attacked with slight engorgement of the testis from the first sitting, was not
prevented by it from coming every third day to have the stone triturated,
and without having reason to repent of so doing. A bath daily ; venesection,
if in a plethoric subject; demulcent drinks, poultices, leeches, and the con-
comitant items of an antiphlogistic regimen if the symptoms are threatening,
combined with rest and tranquillity, are the means to be adopted for mode-
rating or removing them. i
HxmaUma when slight and unaccompanied by fever demands but little
attention; cystitis and peritonitis, which M. Marjolin tells us he has
observed, and such nervous phenomena a§ all writers on litliotrity mention,
require under this the same treatment as under any other circumstances, and
afe owing either to the pain caused by the introduction of the instruments,
the friction of forceps, or of the stone, when it has become angular, against
i\\^ bladder.
The same remark applies to incontinence, partial or entire paralysis of
the organ, and to the weight and burning sensation felt about its neck. Frag-
ments of stone may become arrested in the urethra in such a way as to
close it quite, and produce retention of urine and frightful agony. The
OPERATIVE SURGERY. 839
means of relieving this accident will be found in the previous article — Stones
in the Urethra.
Punctures of the Bladder, on which many persons have laid much stress,
are doubtless possible, for M. Brischet witnessed the operation, but they must
be infrequent in the hands of cautious operators. I need scarcely say thaft
the aid of art would be attended in such a case with little hope of advan-
tage, unless the perforation were without the peritoneum.
One of the accidents about which we are justly most solicitous, is pinching
the organ. Happily it is one which we can almost always avoid. To do
this it is sufficient to be careful never to shut the forceps hastily, and never
to approximate their grasps until we have felt the stone between tl^em,
and at the same time drawing them towards the urethra ; all which are
easily done when the bladder has been previously filled with a certain quan-
tity of liquid, so as to surround the stone. But where the bladder contracts
violently and will retain nothing, when the patient is agitated or the instru-
ment is directed by an unskillful hand, it is easily conceivable that the inner
walls of the organized sac may become entangled in the hooks or branches
of the forceps, and run a great risk of being lacerated. Of this the operator
is admonished by the cries and acute suffering of the patient. Flakes of the
natural tissues withdrawn along with the instrument often furnish melancholy
proof of the fact. Peritonitis or cystitis is the almost necessary consequence
of such an injury, and requires the usual remedies.
Finally, it is possible for the instrument to break in the cavity of the
urinary pouch. If the fragment remains perfectly at liberty, every attempt
to extract it by the natural outlet will be evidently useless, and our surest
course is to perform lithotomy without hesitation. The litholabes invented
bv MM. Meirieu, Tanchou, Recamier, Jacobson, and that of. M. Pravaz,
modified by M. Segales, being kept together at each division by joints or
strings, are generally safe from this accident, as they allow the separated
portion to be drawn out with them.
Art, 6. — A comparative Examination of Lithotrity and Litnotomy.
Scarcely was the breaking up of the calculi known, than it was upheld by
its partisans as a perfectly innocent operation, and one wholly free from dan-
ger. Others have gone so far as to suppose that it was calculated some day
or other to do away with any surgical operation for the cure of calculus.
The public upon both these points have been deceived, Lithotrity as now
performed is in substance a longer and a more painful operation than cysto-
tomy, and I have seen persons, among others one who was cut by M. Souber-
bielie, after some attempts by M. Civiale, declare they had suffered more in
one sitting from lithotrity, than from all the manipulations of cutting for the
stone. One fourth, if not one third of those who submit to it, suffer some
accident, and it is not true that no one ever dies from it. It vvas clearly
proved by M. Heurteloup, that instead of one in forty M. Civiale lost eight
patients out of forty-eight. Of those of M. Leroy three died out of twenty-
eight ; and an analysis of operations performed at the school of Abou Zabel in
Bagdad ; by Mr. Watteman and others in Germany; in England by Messrs.
Liston, Costello, Heurteloup ; in France by MM. Amussat, Bancal, Roux,
640 NEW ELEMENTS OF
Dupuytren ; in fact by different surgeons in almost every country in the
globe, proves that this is about the best result which has as yet been obtained.
If we take all the patients with calculus who have presented themselves to
lithotritic surgeons, and on whom tlie operation of cutting might have been
performed, the result is even less encouraging. Of the eighty-two spoken of
by M .Civiale, thirty-one were dead at the expiration of a year, and nineteen
others recovered only after having met with some accident or other. M.
-Leroy was able only to cure radically twenty -five. Out of ten who offered
; to him, M. Bancal was enabled to operate only upon two ; so that among those
vAio are chosen as its subject, there perished one in ten or twelve at least ;
and in a given number of patients, some being subjected to lithotrity, some
cut, and others left to the resources of the organism, one-sixth or one-eighth
at least are lost. Looking at lithotomy under this aspect alone, it is quite
alarming enough, and it was unnecessary for the enthusiastic admirers of
lithotrity to have darkened the picture of its ill -success to disgust the public
and dissuade the greater number of patients from undergoing it. Still,
tiiough there be authentic records proving that eight hundred and twelve
persons cut for stone in Paris at the Hotel Dieu and La Charite two hundred
and iifty-five died between the 31st December, 1719, and the 1st January,
1728; others again demonstrate that Cheselden lost only twenty-four out
of two hundred and thirteen. While M. Sanson tells us that he has seen six
die out of twenty, M. Dupuytren on the other hand about the same time per-
formed the operation on twenty-six persons before meeting with the loss of a
single individual ; and Dr. Dudley, of Transylvania University, Ky. met with
a like success in seventy -two cases. Though we may not admit the wonderful
success which is by some persons attributed to Raw, or believe that it was pos-
sible for this surgeon to succeed fifteen hundred times in succession, whiph
simply means, that out of all his cases, he succeeded in curing fifteen hundred,
it seems very certain that Mr. Martineau of Norwich has lost but two in
eighty-four; M. Pansa of Naples five in sixty; Ponteau two in eighty;
Lecat three in sixty -three; M. Pajola of Venice nearly the same propor-
tion; M. Viricel of Lyons three in eighty-three; M. Ouvrard of Dijon
three in sixty; Sancerotte one in sixty; and that of Descharaps at one time
succeeded nineteen times in succession. These it is true are but partial data.
The same operators have not been always as successful; but why should not
the same thing happen in lithotrity.^ Although we admit that in 1826 M.
Civiale had lost but one patient out of forty, must it not likewise be con-
fessed that he has not since been as fortunate, and that his practice at the
hospital Necker, according to M. Larry's report to the Institute, offers a
much more considerable proportion of reverses. Nor is it possible to expect
from every one the same ratio of success as from a man so practised as is M.
Civiale.
We must not come with prejudices such as these to the consideration of
subjects of this importance. Senac was perhaps justified in saying that most
of the patients operated on for stone in the Parisian hospitals died; for in
the year 1725 there died sixteen out of twenty-nine at La Charite. Another
person, with equal propriety, might have maintained however that only one
perished out of eight or nine; for twenty -two recovered out of twenty-five
i:i 1727, and twenty-three out of twenty-six in 1720, at the same institution.
I
OPERATIVE SURGERY. 841
All this did not prevent Morand from discovering that in this hospital seventy-
one deaths had occurred in two hundred and eight cases in eight years ; and
at the Hotel-Dieu within the same period eighteen out of five hundred and
ninety-four cases. M. Souberbielle lost eighteen outof fifty-two in 1824 and
1825, but his mean proportion is not less than one in six or eight. Notwith-
standing M. Richerand's opinion that the successful and fatal cases were
about equal in number at the beginning of this century, MM. lloux and
Dupuytren have established them in the proportion of five to six. Lastly, if
figures must be made to speak, the following are the results of the best kept
statistical accounts which have been published in twenty years.
At Norwich in five hundred and six cases, seventy deaths ; at Leeds in
one hundred and ninety-seven cases, twenty-eight deaths ; at Bristol one, in
four and a quarter cases; at Luneville one, in fourteen cases.
In the account of M. Dupuytren, which includes Paris and its environs,
there have been in ten years sixty-one deaths out of three hundred and fifty-
six cases, or one in six. Lithotrity I am well convinced is less fatal than this ;
but it is necessary to ascertain how much less it is so, and this point experience
does not yet enable us to decide. In the settlement of the question it becomes
conscientious men to consider that those persons whose cases admit of litho-
trity are the very ones in whom lithotrit^ would best succeed ; whilst all those
to whom trituration is inapplicable have likewise not much chance of being
cured by lithotomy. The problem therefore cannot be solved definitively,
until a certain number of hundreds of calculus persons subjects for lithotrity
shall be taken, which shall be divided into equal parts, and one half litiiotrized,
and the other half cut.
Though lithotrity may have fewer dangers, it is not in every case possible
to practice it. It is absolutely repelled by calculi, the nucleus of which
consists of some solid body, such as a pin, a needle, a ball, a piece of wood,
of horn or ivory. The same may be said of all calculi which adhere, are
encysted, or in any other way made immovable ; of such as are extremely
hard which are larger than a hen's egg upon which the bladder is kept habi-
tually applied ; if individuals who have deformity of urethra, either congenital,
such as hypospadias, epispadias, or the result of disease, to such a degree as
to make it difficult to use the necessary instruments. The existence of many
stones, considerable enlargement of the prostate, a protracted state of ill
fiealth, or horny induration of the bladder, will render it for the most part as
dangerous an operation as lithotomy. In every other case its advantages
appear to me to be indisputable except in children : more particularly if the
patient is endowed with patience and gentleness, and is of a somewhat
blunted irritability, so as fearlessly to undergo the various manoeuvres-
requisite ; if he dreads cutting instruments so much as willingly to submit to
be a longer or shorter time in getting rid of it, and to suffer as often as is
necessary for the annihilation of his stone the reintroduction of the litho-
tritic instruments. Although a return of the disease is much more probable
than after lithotomy, owing to the remnants of stone which often evade the
most cautious researches, if it appears likely that two, three, four, five, or six
sittings will suffice, we can have no hesitation as to performing it. Lithotomy
is then incomparably more alarming. The latter it is true allows the more
speedy and complete removal of the stone, and the pain is in a measure
106
842 NEW ELEMENTS OF
instantaneous only ; but the patient must be confined to bed or the room for
twenty or thirty days, whilst in the intervals of the sittings lithotrity scarce
disturbs his usual habits.
SECTION III.
The Urethra.
Art, 1. — Catheterism
Catheterism is performed for the purposes of giving exit to urine ; for ex-
ploring the bladder; the cure of certain diseases; and to aid in the success
of certain operations, such as the various operations for stone, lithotrity, &c.
The instruments with which it is effected have long been known under the
name of eathetet^s, which in Germany and England tliey still very generally
retain : but in France are more generally called "5om/es" or '' algalies^^ ; the
last of whicli words however only applies to hollow tubes of a metallic nature.
Solid stems, cylindrical, conical, probe -pointed, or buttoned at the point, of
various substances, may also be employed for this purpose. The terra
" catheter^- is now understood to mean only the grooved instrument used in
sub-pubic cutting for stone.
The object of the surgeon being to penetrate into the bladder of urine by
the natural passage, an acquaintance with the structure of the urethra becomes
an indispensable preliminary, without which catheterism will expose the
patient to very alarming dangers.
§ 1. Anatomical Remarks.
The urethra at the adult age is about nine inches long, sometimes seven or
eight only, and at other times ten or even eleven ; two lines and a half to four
lines in width, but not of equal width in all parts of its extent. Its narrowest part
is its meatus; so much so indeed that some surgeons have been obliged to
cut it before commencing lithotrity. Directly behind it on a level with the
frenum we find the fossa-navicularis, which in spite of what may be said of
late years in most subjects forms a species of excavation here. Next comes
the portio-spongiosa, which extends as far as the root of the penisj and con-
tinues insensibly increasing in diameter as far as the portio-bulbosa, which is
wider still. This part which is but a continuation of it soon contracts itself
very much to become blended with the membranous portion, and is seen
beneath the divergence of the roots of the corpora cavernosa penis in front of
the sub-pubic ligament. After the membranous portion comes the prostatic
portion, encircled as it were by the horizontal aponeurosis of the perineum,
situated directly beneath the symphysis, and where the canal hollows itself
out to close again, and finally widens anew like a funnel at the orifice of the
urethra. It is to be borne in mind that all these excavations exclusively re-
side in its inferior wall, whilst the contracted portions are nearly circular and
comprise its entire circumference. Each of them being deeper behind than
before it causes them to form folds in the former direction, like valves before
OPERATIVE SURGERY. 843
the progress of the instrument. This inconvenience is especially felt in the
fossa-navicularis, and the excavation of the bulb. The former as well as all
the spongy portion, contain besides small veins the lacunae of Morgagni (as
they are called) looking in the same direction, and equally capable of impeding
the introduction of instruments. The prostatic excavation Is still more im-
portant because of the verumontanum, which, of a crest-like shape, divides
it into two from the end of the ejaculatory canals seen on the summit and
sides of this crest and the numerous ducts from the prostate which terminate
in it ; so that the beak of the instrument frequently encounters here a double
depression, extremely apt to lead it in a false direction. I have in some
subjects met a little further on before entering the bladder a semilunar fold
whose concavity was forwards seemingly dependent on an extension of the
lining of the valve of the bladder, and which would equally prove an obstacle
to the passage of the sound. To understand the unequal resistance of the
urethra, it is merely necessary to observe its relations and the structure of its
different parts. Its dorsal side forming the concave edge of the se^rment of a
circle is on that account shorter than the other and less disposed to form plaits.
Destitute of cavity, and strongly adherent to the lower surface of the penis, it
presents much regularity, and so great strength in its spongy portion as scarcely
to be in any danger from catheterism. The corpora-cavernosa, as they go off
opposite the bulb to fasten on the ischio-pubic rami, leave a small portion of
it uncovered almost in front of the symphysis, where it maybe injured by the
beak of the catheter, bruised and even perforated when the instrument is
' parelessly passed and tilted up more than is necessary, so as to butt against
the anterior face of the sub-pubic ligament, or of the horizontal aponeurosis
which prolongs or continues it below. Behind the fascia the dorsum of the
urethra, strengthened by the muscle of Winslow and the upper arc of the pros-
tate and the cellular tissue, has nothing to fear from the action of instruments,
because moreover it possesses there considerable mobility, rises easily against
the pelvic surface of the pubis, and passes gradually into the anterior wall of
the bladder.
The urethra, which in the fossa-navicularis is very thin, being no longer
embraced as at the meatus by the cavernous tissue of the glaiis penis, is in
some measure reduced to its inner and outer membranes ; and is consequently
very weak, easily pierced, torn, and ulcerated. A little further on the
spongy layer separates its mucous tunic from its outer covering, and sensibly
increases its thickness and its strength. But in the bulb this layer becoming too
much attenuated and expanded leaves it again to its original resisting power;
an arrangement the more to be regretted, as no part is more excavated,
and that there we encounter afresh the horizontal aponeurosis. The inferior
wall of the membranous portion, instead of being thinner and weaker, is on the
contrary thicker and stronger than any where else exclusive of the prostate
or the bulb. Embraced by the perineal fascia as by a ferrule, and supported
by the decussation of the fibres of the transverse muscles, it is in itself addi-
tionally lined by a layer evidently muscular, and surrounded by a fibro-
cellular sheath at times of some thickness. It is therefore more common to
observe lacerations and traumatic perforations, at the entrance of the urethra,
into and at its departure from the bulb, than at this part itself; whilst by way of
844 NEW ELEMENTS OF
retaliation itis the chosen seat of stricture. Quite behind it the lower wall of the
urethra is as it were decomposed by the prostate, which seems to be developed
between its two natural layers. It follows that the mucous coat is now its
only membrane as an independent wall; that this membrane makes one body
with the gland, and can neither plait, contract, or be the seat of spasm or
contraction ; but that it is easy to perforate, excoriate, and more readily takes
on ulceration and profound disorganization, or forms abscesses; in a word,
tliat it makes common cause with the prostate gland as respects diseases and
pathological alterations. The fleshy fibres between the prostate and the bulb
in the urethra, which anatomy compels us to acknowledge, even though
practice had not a thousand times demonstrated their existence, do not allow
of our doubting the contractile faculty of this canal, or the possibility of
spasmodic stricture, which among others Mr. Charles Bell denies. These
spasmodic strictures are of equally indisputuble occurrence in front of the
membranous portion, and even to the forepart of the penis. I have seen them
in two dogs, and the use of a bougie will often enable us to study them in
man. It has now happened to me twenty times at least, to push a conical
2;umelastic bougie to a depth of five or six inches without the slightest diffi-
culty ; then directly afterwards to find it so strictured that it required an
exercise of strength to withdraw it; that in its withdrawal it was easy to feel
the friction and that the canal parted with it in a measure with regret. In
some instances besides these contractions have been evident enough to expel
the foreign body, and push it forwards several inches before my eyes, although
no effort had been necessary to cause its introduction. The value of such
facts can be weakened by no speculative reasoning. However, the presence
of fleshy fibres is not indispensable to their explanation. The elastic element
of the bronchi, the outer layer of the ureter, the deep envelope of the scrotum,
the soft, velvet-like cellular tissue of the perineum, &c.all enjoy, I am satisfied,
a species of contractility; and yet we may assert that in these lamellae there
exist no muscular fibres.
The direction of the urethra is another point which must not be forgotten.
While the penis is in a relaxed state the canal presents a double curve; the
one forward and its concavity downward ; the other behind, and its concavity
upward, of the shape of the roman S. During erection, or when it is raised
towards the abdomen, the urethra loses the former, and assumes the direction
of the segment of a circle whose concavity is downward ; much more concave
behind than before, and very much the shape of a rib in this respect. The
other is a fixed curve, which begins in front of the symphysis, ends at the blad-
der, comprising the bulbous, membranous, and prostatic porticms ; and depends
upon the attachment of the penis to the anterior surface of the pubis by a liga-
ment of slight, extensibility, whilst another fibrous riband keeps the prostate
behind the symphysis, and also upon the circumstance of the bladder being
pushed up towards the abdomen by the rectum and the prostate, whilst the
urethra outw^ardly is obliged at the same time to rise upwards and forwards to
gain the lower face of the corpora cavernosa.
From all this it follows that the curvature of this canal is not invariably the
same ; that iu extending towards theischia, as often happens in man, and almost
naturally in children, the sympliysis and sub-pubic ligament may very mucli
increase it; and that enlargement of the prostate, fullness of the intestine, and
OPERATIVE SURGERY. 845
thickness of the perineum must produce eifects of the same kind, less diffi-
cult to be overcome.
. The urethra, therefore, is neither straight nor almost straight^ and to main-
tain this would now be absurd. Those who, along with Rameau, Lieuteaud,
Santarelli, C. Bell, and others, asserted it, could never«have thought so, or else
their eves were blinded by a wish to discover arguments in favor of rectilinear
catheterism. If the urethra were straight it wpuld be prolonged in the direc-
tion of the bulb, following a line which would fall on the point of the coccyx
passing over tlie anus. Instead of this what does it do in reality ? It is seen
to separate from its spongy tissue gradually from the bulb entirely, to pass
through tlie aponeurosis under the pubis, enter the pelvis, and end two inches
at least from the level of the anus, and consequently above the direction of
the line of which I have just spoken. This mathematical remark leaves no
room for reply, and would alone suffice to establish the question, should any
one be pleased to revive it. Still, when the symphysis is short, the prostate of
no great thickness, the urethra crosses it nearer to its lower than its upper
surface, and the pelvis is large, tractions upon the penis do in a great measure
cause this curvature to disappear, and allow of our passing straight instruments
v/ithout any great obstacle into the bladder; which in turn morie or less for-
cibly depress the floor of the prostatic portion of the canal and cervix vesicae.
§ 2. Examination of Instt-umenis and Methods.
Catheterism, whether, as it is called by M. Roux, it be Evactmni^ Explorative,
Directing, or Derivative, is performed in general after the same rules in every
case.
The copper catheters (sondes) which were once used were attended with the
inconvenience of becoming oxidized, and covered with verdigi'is, and
are now universally superseded by silver ones. Flexible catheters of horn,
leather, and spurious metallic wires, having been used only in default of
something better, equally deserve to remain in the neglect into which they
have fallen since the invention of elastic catheters, by Theden, Pickel, and
Bernard the goldsmith. Silver and indian rubber instruments then are the
only ones worth preserving ; the first for cases in which their solidity is de-
sirable, and in which the catheter is to remain but a few minutes in the
urethra ; the second for those in which after the operation it is advisable to
leave them for some time in the bladder.
The length of a metallic catheter for an adult man is about twelve inches.
If shorter they will not in some old men reach all the way to the re-
servoir of urine. If longer they will expose the bladder to perforation and
the organs to injury. Their diameter should vary from two to three lines.
Due proportion being preserved they pass better the greater their volume. For
children they are made of a line or a line and a half diameter, and from five lo
eight inches in length. If their sides are too thin, they become liable to bend, get
out of shape, or even break on the slightest eftbrt. A contrary construction
makes them more expensive, usurps room in their cavity, and will interfere
with the flow of urine, unless the caliber of the instrument is otherwise very
large. Their free end is generally expanded, of a funnel-shape, and has a small
ring on each side, to which on occasion strings or ribands may be attached.
At a distance of a few lines from the other end, which is blunt, are two lateral
846 NEW ELEMENTS OF
elliptical apertures, instead of a mere slit wliich used to be seen in them. We
now scarcely use any longer than those which instead of d beak have a stylet
head, which is pushed forward to open them and whicli closes them when drawn
towards ourselves ; nor those either which are free and open at the vesical end.
The curve which has been given them, has been the source of much discussion.
It is easy to push on a straight instrument like a cylinder by making it revolve
on its own axis, and thus overcome obstacles which could not with one of
another shape have been surmounted. But this advantage is more than coun-
terbalanced by the pressure which their beaks cause against the floor of the
membranous and prostatic portions of the urethra, and their tendency to make
a false passage. Crooked instruments give less pain, enter better, and are in
every respect preferable.
The S shaped catheter of the ancients revived by J. L. Petit, so as not to
fatigue the canal so much when permitted to remain in it, has become useless
since the addition of flexible ones to our science. A very great and very length-
ened curve does no good, and serves to impede the motion of the hand. That
curve which is confined to the end of the catheter, as Rameau suggested, and
as Mr. Key has since advised, enters more easily than a straight catheter does,
but pulls quite as much on the sub-pubic portion of the urethra. The most
convenient we have are curved only in the posterior fourth of their length, in
such a way as to form an arc whose string is but three or four inches long, and
its radius not more than two or three. I have found those most useful, the
axis of whose beak is carried to the point of crossing the supposed continuation
of their length at a right angle, and especially incises where the prostate is
enlarged. The more it projects backwards the more diflicult is it for it to
enter the bladder, and not butt against the lower wall of the canal after it
leaves the perineal aponeurosis. The silver wire which they are supplied with
is hardly ever of any use, and has not even the advantage of being able to clear
the eyes, or clean the interior of the instrument when stopped up by any fo-
reign body.
Position of the Patient. — In most cases it is a matter of indifference whether
the patient be standing up, sitting up, placed upon the edge or foot of the bed,
or table, with his legs hanging down or supported, or else lying on his bed as
usual. The latter, however, being the most convenient position, is that
which is most commonly adopted. Semiflexion of the limbs and separation
of the thighs which are recommended are not of miich importance, though
they give more ease to the operator, and may perhaps contribute to stretch
and unplait the urethra. The same remark applies to the s^tate of the head,
belly, and chest, all of which should it is said be sedulously relaxed.
Position of the Surgeon. — Unless the surgeon be ambidexter he stands
necessarily upon the left side, and can only take his station facing the patient
or between his legs, if it is his wish or it be necessary for him to be operated
on out of bed. With his left hand half supinated he seizes the sides of the
penis between his ring and middle fingers, and with the forefinger and thumb
pull,^ back the prepuce so as to uncover the glans, or at least the meatus.
His right holding the catheter, held like a pen, its concavity being towards the
abdomen presents its point to the orifice of the urethra perpendicularly, and
so carries it on without raising the handle to the bulb, by a see-saw motion,
performed from right to left or from the abdomen towards the space between
OPERATIVE SURGERY. 847
the thighs, a circular motion in which the two extremities of the catheter seem
pursuing one another. He then introduces it into the membranous portion be-
neath the pubis, causes it to pass the prostate and all the crooked part of the
urethra, so that, as it were, it embraces the posterior surface of the sym-
physis, and its hollow portion is in the axis of the lower straits Urine flows
out directly, and the thumb, opening or closing the orifice of the artificial
tube, allows it to flow or be restrained as need may be.
Difficulties in the Operation. — Catheterism is not always thus simple, and
by times presents serious difficulties. It is a thing which requires custom
and skill, accurate anatomical knowledge, and several precautions. If the
beak of the catheter bears too much on the lower wall of the urethra it will
glide on with difficulty, and be stopped at the fossa navicularis at the bulbous
cavity or in the prostatic depression, and go astray in some one or other of
these dilations. These circumstances we need not fear if it be made to fol-
low the upper wall uninterruptedly unless it is raised too much, or unless its
axis, instead of corresponding with that of the canal, fall at a greater or less
angle on the surface over which it is to pass, and even this improper direction,
unless it is excessively out of the way, will have no real inconvenience until
between the roots of the corpora cavernosa ; and when it an-ives at the ante-
rior face of the symphysis all that is required is to pass the catheter along in
the axis of the urethra from the meatus to the bladder, holding it gently
pressed against its dorsal region. No fixed rule can be given on the subject,
because the relations of this axis with that of the body are never constant.
In some, the handle of the catheter requires to be held, so to speak, parallel
to the walls of the abdomen whilst it is passing through spongy portions of the
urethra ; whilst in others we are obliged from the commencement to bring it
into the plane of the lower strait. Violence however is never necessary. The
instrument must progress as much by its own weight as by the influence of
any external cause. If we meet with resistance to it, it is to be withdrawn
a little way, and then inclined and urged on in another direction. By adopt-
ing the advice given by Le Dran and many other authors since, that of draw-
ing back the urethra upon it from below upwards and from behind forwards,
we create numerous obstacles instead of doing any away. It is a precaution
which can only be useful in the penis portion of the canal. Further on it
flattens it, tends to press it against the sub-pubic ligament, and can only facili-
tate its laceration. The way to enter the bladder safely is to let the catheter
descend freely to the commencement of the membranous portion ; that is t»
say, down to the level of the lower edge of the symphysis, so that it may nei-
ther depress the upper wall nor lower wall of the urethra against the peri-
neal surface of the horizontal aponeurosis; then suddenly to give it the
see-saw motion, though without any effi:)rt, depressing the handle from before
backwards until it becomes parallel with the axis of the thighs. This move-
ment, unless the beak is on this side of the pubis, carries it at once into the
bladder. If not, it butts against the symphysis, the penis bends, and the
instrument springs back instead of advancing. This difficulty is generally
to the operator's being afraid of depressing the outer end too niuch, scarcely
fancying how very much its point must be raised so as not to be embarrassed
by the posterior tubercle of the prostate.
If we encounter difficulty in approaching the symphysis, we are to employ
848 NEW ELEMENTS OF
the left hand in ascertaining the cause by raising the scrotum, exploring the
perineum, and trying to detect the beak of the catheter through the canal with
the fore and middle fingers, and to follow its movements. If the instrument
have gone on a little further the forefinger must be passed into the intestine
through the anus. There, as above, acting as a guide and means of exploring,
it informs us precisely in what direction the eiforts of the other hand are act-
ing ; and if we are still in the membranous portion, or in the prostatic, we feel
through the thickness of the interposed tissues whether we are likely to create
a false passage, and it may even assist us in tilting the catheter towards the
bladder. We must however not labor under any error as to the value of this
manoeuvre, which is in no way applicable to rectilinear catheterism. In rais-
ing the prostate the finger increases the curve of the urethra, presses it-^et
more strongly against the sub -pubic ligament, and naturally offers the soft or
lower wall to the beak of the staff.
To derive all possible benefit from it, it is necessary, as soon as the state of
parts is recognized and the least effort is about to be made, to draw the pulp
of it a little forward, and fix it on the convexity of the instrument at a short
distance from its end. By doing this that portion of canal which has yet to
be passed over suffers no pressure capable of increasing its curve, and the
combined action of both hands is unattended with danger. The signs which
show the catheter to have entered the bladder are so evident in most cases
that they speak for themselves, and require no description. But in many
instances several may be wanting, and the diagnosis be so obscure as to puz-
zle a surgeon. If thick mucous matters, clots of blood, &c., clog up the eyes
of the catheter, urine will not flow out. Instruments which are very much
curved keep sometimes so closely applied to the anterior wall of the bladder
that they remain motionless and closed even above the upper strait. When
the urinary pouch is empty, contracted, or very narrow, we can penetrate to
so little depth, and the movements of depression, elevation, and rotation to
the right and left of the catheter so limited that one is really led to doubt its
having entered, and to be uncertain as to the place it occupies. A consider-
able mass of blood accumulated in the anterior part of the bladder, which M.
Mathieu saw, would be very liable to deceive one, as all the thickness
must be penetrated before arriving at the urine. The catheter has
besides been known to enter deeply the thickness of the recto-vesical septum,
and perform its motions with almost as much freedom as if it had been in the
bladder. If a large excavation or adventitious pouch of greater or less size,
following an ulceration of the floor of the urethra, become hollowed out in
the thickness of the perineum in front of the rectum, of which I saw a re-
markable example in a young man who died in 1825 at the hospital of the
school, and of which M. Roux says he has seen several, the error becomes
still more easy. In fact, the cavity may be mistaken for a diseased bladder,
more particularly as the catheter on its entrance gives exit to a small quantity
of urine. Hence the sensation of overcoming a resistance beyond the pubis,
the freedom that we perceive directly about the deep extremity of the instru-
ment, the possibility of moving it in every way without marked pain to the
patient, the road and direction it must have taken, and lastly the issue
of urine, prove that we have entered the bladder ; but there are circum-
stances in which many of these signs may be wanting, and others simulate
OPERATIVE SURGERY, 849
them more or less completely. If we cannot pass it, after having tried ia
various ways, it is well to take another instrument with a dift'erent curve,
either greater or smaller, according to what we think is indicated ; or to select
one of larger caliber, which by opening and unfolding the canal in a more uni-
form manner, often passes where a smaller one had been stopped. At other
times we succeed better with a catheter of a sensibly less size; or then
attempt the use of gumelastic tubes. The position of the patient is to be
changed and varied ; and when the difficulties which present themselves caa
110 longer be attributed either to the operator or the instrument, we proceed
to the examination of such as may arise from the condition of the canal itself.
The obstacles chiefly encountered in this part are the following : congenital
or acquired tortuosity, deviations resulting from disease, congestions, tume-
faction of the mucous membrane or its surrounding tissues, a varicose state
of the prostatic plexus, an excessive development of the verumontanum or
vesical valve, a fibrous or any other tumor upon the posterior edge of the
prostate or trigonal space, and lastly, spasmodic contractions of the peri-
neum and urethra. Some of these are obviated by well-directed motions.
The others require to be combatted by different measures. A large bleeding
from the arm ; leeches between the scrotum and anus ; warm baths continued
for a long while if the patient is robust and suffers much ; opiate draughts ;
ointments of a similar nature, such as belladonna and hyosciamus placed in
the anas, and along the course of the urethra when the irritability is very
great, and there can be no doubt that the movements are spasmodic, consti-
tute the series of means to be employed on such occasions. By using judi-
ciously and successively each in its turn, a well informed and skillful surgeon
will scarcely ever fail to succeed. If spasm of the urethra, properly so
called, really exist, and we can wait for some hours without risk to the patient,
it must be treated as I have just described ; but in urgent cases every thing
must be done to get through it, and I have my doubts whether to a skillful
hand it can really form an insurmountable impediment. It is so convenient
likewise for clumsy people to assert, as they do, that there is a spasmodic
contraction merely because they cannot pass the catheter into the bladder!
As a constriction of this sort must necessarily be of short duration, and does
not entirely obliterate the canal of the urethra, it must with patience and
small instruments be in the power of art to overcome it.
Flexible Catheters, — The urethra is passed with flexible catheters, as by
the preceding ones. Still as a general rule it is correct to say that they do
not pass so easily as silver ones. If they are to be made to pass a tortuous
canal they should have no stylet, so that they may bend freely in every direc-
tion. In an opposite case, the caliber is filled up by a metallic rod as strong
and smooth as possible. This rod, curved as catheters generally are, becomes
the guide of the instrument, should fill it quite to its point, and at its handle
end exceed it in length, and generally terminates in a ring. " We must be
extremely careful that the stylet does not escape through tlie eyes of the flexi-
ble sheath, as it might expose the urethra to a very dangerous injury. It is
best before introducing it to give it the proper shape, although it is easy to
increase its curvature after it has passed the pubis, by slipping the finger into
the rectum. To withdraw the rod we have only to bring it towards the
abdomen with the right hand, whilst the left hand holds the catheter below
107
840 NEW elements: OF
and pushes it towards the bladder. If this manoeuvre is sometimes more
painful tlian the operation itself, it is because it has been badly executed ;
and never happens when the stjlet is made to pass over at its exit the same
segment of a circle which it traversed at its entrance.
Some surgeons at the instance of Dr. Hey have approved of the plan of no
longer using the stylet after reaching the pubis ; but to hold it firmly in one
hand while the other makes uniform pressure on the catheter, whose blunt
and flexible beak passes better along through the remainder of the urethra,
than if it were directed by the stylet. Others, following up an idea of Dr.
Physick, use an instrument whose summit is lengthened out in the shape of
conical, flexible, and full point, which goes before the stylet. Dr. Hey with a
view to fatigue the bladder less, contrived to give the catheter a fixed curve,
which many French surgeons have adopted^ and whose only inconvenience
I think is that of being rather too prominent.
Gumelastic instruments being preferred only in cases in which it is useful
to leave them in the bladder, call for the utmost attention of surgeons on this
subject. In the first place their composition should be such that no bending
can break them, crack them^ or destroy the softness and polish of their sur-
face. If this is not attended to they soon become rugous in the urethra, and
are soon incrusted with urinary salts; and if, as has often happened unfortu-
nately, a piece falls off into the bladder, every one knows what the conse-
quences will be. The best way of trying them is to make them bend and twist
suddenly on their axis. If they resist and do not alter in appearance they
may with confidence be employed. If otherwise, they should be refused.
The red wax edge which is placed round their free extremity is useful, not
only as a groove for the strings which serve to fasten them, but it also prevents
them from being lost in the urethra, and from slipping towards the bladder,
by escaping suddenly out of the hand. It does not at first sight appear
possible for a catheter ten or twelve inches long, left to itself, to enter wholly
into the bladder ; but of its occurrence we have proofs the most incontestible,
and even last year M.Rouxwas called upon to perform cystotomy for an
accident of this kind.
An infinite variety of methods is practised for fastening a catheter in the
bladder. Sometimes the ribands which go round the head are led up and
fastened to different parts of a T bandage, the two perpendicular branches of
which go round the inner surface of the upper parts of the thighs. Some-
times they are attached to a waistband and drawers, at others they are tied
to little strings coming froni the front of a suspensory, such as is to be met
with readily prepared at the bandage makers. Instead of four strings, two
Tip and two down, placed at equal distances from the root of the penis, some
have them made with double rows of button holes, others with small rings
formed like the handle of a basket. In hospitals the penis is first passed
through a hoop covered with linen, which is then fastened by strips of bandage
on the front of the pubis and scrotum, so in short as to serve for a common
rendezvous for the ribands of the catheter. All these methods are good, in
as much as that they make no pressure on the penis ; but they all are more
or less inconvenient, and have the objection of acting both on the pelvis which
i« not, and the penis which is movable. The best way after all is to fasten
the catheter on the body of the organ itself, which suffers much less indeed
than has been a&serted when suitable precaution is observed in doing it. With
OPERATIVE SURGERY. ^51
me the following plan has always been effectual. We take two strips of
cotton, rather thick and half a yard long. Cotton wick will answer every
purpose. The surgeon makes a simple open knot in each string, places each
on the catheter a little below the glands, and then draws the knots close,
leaving the four ends separate and pendant. He then takes, adjusts, and
approximates the two ends of the first string, passes one end within the other
so as to form a loop an inch or two from where they are knotted, applies this
loop against the penis ; passes the end of the loop round it, crosses them, brings
them back again to the side whence they started, and ties them in a bow.
He then does the same with the second string ; carefully arranging the whole
so that there are four strings equally tense having the instrument as an axis
or a starting point, and the body of the penis for a basis or termination. As
from the suppleness of their tissues, they scarcely irritate the organ, it sup-
ports them very well. Instead of one or two turns, we may if necessary
pass them several times around the corpora cavernosa, so as in a measure to
cover the whole penis from the root of the glands to the pubis, by carrying
the cotton wick round often enough. We may also, as M. Roux prefers,
previously surround the penis with a piece of fine linen, so that the strings
may not be in immediate contact with the skin ; but these little changes, as
they are matters of choice only, do not deserve discussing seriously. If erec-
tion or swelling of the organ obliges us to adopt some other course, any one
of those described in the commencement of this paragraph may be pursued.
A precaution which it is not less important to attend to is not to keep the
catheter in too deep ; for though a flexible one it may create inflammation
and ulceration of the bladder, and even perforation, of which we possess many
examples. On the other side, if its holes are not beyond the prostate, urine
will not enter, and the instrument will be useless. It is better upon the whole
not to leave more than an inch or two in the interior of the bladder ; and to
fasten the retentive apparatus near the glands in a relaxed state of the organ
and not on the handle or at the extremity, unless it is our wish that the urine
should issue guttatim. The catheter thus arranged is stopped up with a little
wedge or plug of wood, a sort of spigot which the patient takes out when he feels
a desire to urinate, and puts in again directly afterwards. As it does not abso-
lutely interfere with his walkino;, it is made more comfortable, and kept in more
safety by being cautious to have it gently turned up with the penis on the pubis
by means of a bandage. Prudence requires that every two, three, or four
days it be taken out and cleaned ; and that it be changed if it appears in any
way altered, whicli happens every eight, ten, twelve, or fifteen days. By
keeping it in longer than this, we run the risk of finding it coated with saline
concretions, which may lacerate the urethra as it is withdrawn.
The Masterturn. — In former times lithotomists and great surgeons had a
peculiar way of introducing a catheter. To do it they turned its concavity
downwards, and brought it towards the abdomen by a semicircular turn,
only at the moment of the arrival of its beak beneath the sub-pubic liga-
ment. The remainder of the operation was not different from the pre-
ceding ; and the perfection of the slight of hand consisted in making the
circular turn end insensibly in the tilt upwards, which alone could justify
the expression "masterturn," or {tour de maitre). It was for a long time
supposed that the only object of this method was to conceal the true mecha-
95^ NEW ELEMENTS OF'
nism of the catheter from, the eyes of their assistant, but there is beneath it
I think something more than this. The end of the instrument passed in this
way executes a rotatory motion in the curved portion of the canal, which must
undoubtedly aid its passage beneath the symphysis; and which thereby com-
bines the advantages possessed by straight instruments with those of curved
ones. But as it is a delicate attempt, which in every one's hands would not
be unattended with danger, it has been generally discountenanced or reserved
for a few special cases. An extreme protuberance of abdomen, for instance,
and the operation for stone, when we stand facing the patient to introduce the
instrument, render it unnecessary. It is not even then indispensable, for
there is nothing to prevent us from turning the handle of the sound to one
side during the first stage of the operation, if the size of the belly, and the
uneasy forced position of the surgeon do not allow of its being directed as
usual.
Catheterism in the Female, — The female catheter is but from five to seven
inches long and nearly straight. It is generally an exceedingly simple thing
to introduce them. The canal through which they have to pass is so shoct,
so regular, so easy to find and to follow, that it scarcely resembles that of
the male in any respect. The patient is more conveniently placed when she
lies on her back, than when standing up or seated on the edge of her bed»
The surgeon, who stands on the right side rather than on the left, desires her
to flex her limbs gently, and to separate her thighs. He then places his left
hand in supination on the pubis ; opens the labia minora with the thumb and
middle finger ; raises the clitoris and vestibule with the index, the nail of
which is kept towards the meatus ; takes the catheter previously greased,
and holds it in his right hand like a pen ; passes it beneath the right ham, if
the breech and vulva seem too much sunken ; offers the beak with its con-
cavity upwards to the orifice of the urethra, lowers it a little to get it
beneath the symphysis; raises it again immediately, and with one effort
passes it into the bladder. I shall not here repeat the means for maintaining
this instrument in its place, having pointed them out fully in the article on
** Vesico Vaginal Fistula." This is an operation so shocking to the delicacy
of some women, that we should be happy if it could always be done without
exposing their persons. Generally this is possible and even easy. If the
left hand being placed as above described, the beak of the catheter is carried
to the nail of its forefinger, it is afterwards only necessary to slip it down-
wards, following the median line on the vestibule, to fall almost certainly
upon the meatus. We should be still more certain to succeed by passing
the instrument from below upwards, resting its extremity against the pulp of
the right middle finger, whilst the ring finger of the same acts as a sort of
explorer or sentinel. It easily detects the fourchette, then the entrance,
then the anterior column of the vagina, the termination of which more or
less swelled like a tubercle, is found immediately below the urethral orifice.
At this point the ring finger stops. The others then slip the catheter over its
fleshy part, using it as a director. The meatus cannot be more than a line
or two off; we feel about a little and almost always easily enter the canal.
In women who have had many children, in old age, and during pregnancy,
&c. the urethra is at times pretty difficult to find. It has retreated into the
pelvis and behind the pubis and becomes very oblique, or even rises quite
OPERATIVE SURGERY. 853
against the symphysis. In such a case, the meatus must be looked for deep
under the pubic ligament, and if it does not soon show itself, we try to bring
it into view by pulling upon the base of the clitoris and the vestibule
upwards, with the index finger, whilst tlie middle finger and thumb at the
same time pull the nymphze strongly outwards. When the catheter is intro-
duced the handle must be rapidly lowered. We are even obliged sometimes
to employ one with a more considerable curve, or even to resort to the male
catheter. Even when the points are in an unnatural, distorted condi-
tion, as in the few first days following delivery, for instance, if the surgeon
will remember that the meatus urinarious is always situated on the edge of
the vagina, at the junction of the circumference of the opening of the vulva
with the base of the vestibulum, in other words, at the base of the small trian-
gular opening bounding the inner surface of the labia minora and lower
surface of the clitoris, he will find that in no case is catheterism really a
difiicult operation in the female sex. It is rendered more troublesome in early
youth, merely by the intractability of the patients. The catheters require to
be less thick (say one or two lines) and less long, (say from five to seven or
eight inches) but to be prepared, introduced and fastened in the same way
as is done in adults, only it is well to have the curve a little longer, because
of the symphysis at this age descending lower, the bladder beins higher, and
the prostate less bulky.
Jlrt. 2. — Strictures,
The means which have been proposed and put in practice, in the treatment of
organic contraction of the urethra, are catheterism, forced injections, dilation,
cauterization, incision from without inwards, and scarifications.
§ 1 . Catheterism hy Force.
When there exists a complete ischuria, and the obstacle causing it can by
no manipulation be done away, either by using a metallic or gumelastic
instrument, straight or crooked, hollow or solid, or with bougies of different
kinds, and the case is urgent, no choice is any longer left the surgeon, but to
perform puncturing the bladder or to effect catheterism by using actual force.
This operation had been advised since the time of Dease, and to do it a
catheter ending in a trocar point had been employed. Now those persons
who venture upon performing it, use a conical instrument suitably curved
and very strong. Credit for the idea is given to MM. Desault and Boyer ;
but Colfiniere, who violently contested their claims, declares tliat it belongs
to him, and that he promulgated it in 1783. According to M. Boyer, Mr
Roux is the only person in France who has taken up its defence ; and except
Dr. Physick, who is said by Borsey to have used a similar practice since 17'95,
it has found only undervaluers in the surgical world. It has been thought
that by thus forcing a way through the impediment, the instrument must make
a false passage and tear the canal very much oftener than it could pass the
narrow part by violence ; and to those who know the dangers which attend
urinal infiltration, the idea of such lacerations has been extremely alarming.
Nor do I think that it is a point upon which practitioners generally have de-
S54 NEW ELEMENTS OF
•ceived themselves. In spite of all his skill and all his practice, M. Roux hasi
more than once demonstrated the dangers of his method. I once myself had.
occasion to open the body and dissect the urethra of a man who had been
treated by him in this manner, and who died of urinal abscess caused
hy a false passage. However, the danger certainly appears to have been ex-
aggerated. A well conducted instrument does not always swerve from
the natural course on clearing the resistance. Besides which, when it really
ruptures, instead of doing it away and it escapes from the urethra, it generally
re-enters it some lines further on. Lastly^ supposing it to reach the bladder
only after freely ploughing up the body of the prostate, this accident even is
far from always proving fatal. The catheter remaining in may change the
false passage into an accidental canal, and yet the organism scarcely take
notice of it, as I saw in an instance in 1830, at a hospital in Paris. Neither
is it uncommon to see the urine resume its course in a few hours, or after
some days, through the natural channel ; and upon the whole I do not know
whether persons sure of their hands and of their anatomical knowledge, so as
not to fear to stray in going through the perineum, ought not to prefer forced
catheterism with a conical sound to puncturing the bladder.
Method of Operation. — The patient and surgeon take their places as for
simple catheterism. The more weighty and solid the instrument is, the better
it penetrates. A common catheter exposes us more than any other to lacerate
the part, nor will it enter the urethra easily enough unless the cone which it
represents be prolonged insensibly up to the handle. Its march would not be
progressive enough if it only occupied the vesical extremity ; and having once
left the canal, it would advance too rapidly into the adjacent tissues.
Generally it becomes necessary to make use of force only after leaving the
bulb and level of the symphysis. From that time the surgeon with his right
hand approaches the glans penis ; takes hold of the instrument by its middle,
and not its handle, that it may vacillate less, and so that he may with greater
ease hold it with all necessary firmness ; pushes it accurately onward in the
known direction of the urethra, not allowing it to deviate in the least, and only
urges it forwards in proportion as the fingers, one or more, of the left hand on
the penis or in the anus, follows its motions and can appreciate its progress,
and make him certain that the beak scarcely departs from the centre of the
membranous and prostatic portions of the canal through which it passes.
False or New Passages. — By tearing the urethra in its bulbous portion,
the catheter is liable to plough up the whole extent of the perineum and
recto-vesical septum, may even make its way into the intestine before it
again finds the canal, and not enter the bladder at all. The false passage
consequently is so much the more dangerous as it does not even give exit to
the urine.
If the tear has taken place above, and the point of the catheter has got up
behind the symphysis and in front of the bladder, the misfortune will be
greater still ; for infiltration having to attack the pelvic cellular tissue ^/ould
almost infallibly produce death. False passages through the prostate are in-
finitely less alarming ; 1st, because the tissues of this gland resists the contact
of urine, and generally prevents infiltration ; 2d, because the instrument not
being far away from the organ to be voided, returns to it almost constantly
before much damage is done, or a great space outwardly passed over.
OPERATIVE surgery:. 855
As soon as we are conscious of having met with this misfortune, we must,
unless it be complete, withdraw the catheter towards ourselves, and do all in
our power to find the urethra and re-enter the natural passage ; or else if it
communicates with the bladder leave the instrument in until such time as
it can be replaced bj a gumelastic catheter, which must be left in for
several days. When infiltration takes place, and swelling and infiltration are
beginning, whether the bladder be empty or not, and whether or not it be
possible to place an instrument in the uretlwa, we must not hesitate ; we are
freely to incise the presumed course of the laceration and to endeavor to get
to the canal. It is the only means of limiting the extent of evil, and of pre-
venting mortification of the tissues.
§ 2. Forced Injections,
A means which should be tried before paracentesis vesicae is resorted to,
and which is not attended with the same dangers as catheterism by force, is
distention of the urethra by a liquid pressed in from before backwards. It
was first mentioned by Tyre in 1784, who says that he has derived the great-
est advantage from it; and Soemmering states that if he is unable with the
most delicate bougie to pass the stricture, he injects oil into the canal, closes
its orifice directly, and presses upon the urethra so as to make the oil pass
from before backwards.
Brunninghau sen's method is a little different; he, at the moment when the
patient attempts to make water, presses upon the urethra strongly behind the
glans and compels the fluid to retreat, thinking thereby to overcome the
stricture. About ten years ago M. Despiney de Bourg proposed a liquid of
a purely emollient nature, which was to be pushed on with a syringe. M.
Citadini who in 1826, in the month of March, published a work upon this
subject, carries an open catheter down to the impediment, keeps the urethra
firmly and closely applied to it, and uses it as a syphon for the injection of
tepid water with all necessary force, or of any other appropriate fluid into the
canal. M. Amussat, who believed himself to have invented forced injections,
does very much as M. Citadini. He advises the application of a compress
around the penis, so that no void may remain between the catheter and the
parietes of the urethra; then that a bottle made of caoutchouc, filled with
water, be adapted to the top of the catheter, and that the injection be thrown
in by compressing the gumelastic bag with a tourniquet. But it is very clear
that, if the principle be but established, it can be of very little consequence
whether the liquid be projected by a syringe, gumelastic bag, the fingers, or
in any other way. This method, though a rational one, and one which in
certain cases is of undoubted efficacy, is still far from deserving all the praise
which some persons have lavished upon it.
If the urine, which is a kind of natural injection flowing from behind for-
wards, neither can break through the stricture, cause it to disappear, or
prevent its occurrence, how can we hope that any fluid whatever, merely
because it is forced in an opposite direction, should triumph over every ob-
stacle? It is therefore very probable that the success which is attributed to
it, may have resulted from the use of catheters and bougies directed judi-
ciously; and that in a majority of instances injections might have been
856 NEW ELEMENTS OF
rendered unnecessary, by a most skillful employment of the ordinary means.
Still as it is easy to use them, and they are attended with no inconvenience, I
see no reason why they may not be essayed, even without waiting for the
failure of other methods.
§ 3. Incisions or Scarifications of the strichir eel part.
Although^'a very old one, the idea of carrying down a cutting instrument to
the bottom of the urethra, to destroy its contraction, lias never had many ad-
vocates ; and I wonder that it should ever have been attempted to revive the
practice in our own time. Besides the almost utter inability to cut nothing
but the strictured part, the danger of cutting healthy and not diseased struc-
ture, and the dread which the patient must feel, another inconvenience about
the method is, that it offers no chance of a permanent cure, and that it renders
the stricture, after the little wounds have healed, tighter than it was before. In
fact, one of two things must happen ; either we must leave the canal to itself
after the incision, and in this case the wound having to heal by first intention
will be closed at the end of four days, or else it must be kept open by means
of catheters and bougies, and then we shall have mediate cicatrization. Now
it is actually demonstrated that these secondary cicatrices, when left at liberty,
contract invincibly upon themselves, leaving the stricture in just the same state
in which the knife found it, if it be not even much harder, and much more diffi-
cult either to overcome or to destroy. The facts which are arrayed against
this reasoning, prove nothing; because, supposing them to be true, the dilation
which is called in to aid the incision, is of itself sufficient to explain the success
which is obtained. But more than this, most generally the incision has not
even touched the stricture, and of course if it seems to give way directly, it
is because of the effect of the dilator instruments, which urethrotomists never
fail to pass immediately. Practice daily furnishes evidence that after the in-
cision, relapses follow as after simple dilation. I have beneath my eye, at
this very time, two remarkable instances of this, who have been cut each of
them twice, at an interval of a year, by one of the most ardent and presuming
scarifiers in Paris. It is a method which can do only for frsenum, vulvular, or
semilunar strictures, if any should be met with in the anterior third of the
urethra ; but which beyond the bulb will be attempted only by the inconside-
rate, who are wanting in accurate surgical or anatomical knowledge — only
empirics.
The Method of Operation. — As it is possible that there will be some who,
notwithstanding the above remarks, will continue to practice incisions, and as
likewise they may become necessary in certain cases of well defined stricture,
too hard and too thick to yield to the distending efforts of a bougie, I shall
describe the method of doing it.
Dorner, to whom the credit of it is given by Siebold and Soemmering, advises
the use of a sort of lancet, passed through a catheter. Dr. Physick highly re-
commends an instrument of the same kind, a stem ending in a fleam point, en-
closed in a canula of sufficient length, of which it is forced out by pressure
on its free extremity. In the work of Dr. Dorsey, two of these urethrotomes
may be seen ; one of which has no curve whatever, being intended for strictures
of the straight portion of the canal ; the other rather more curved near its beak
OPERATIVE SURGERY. S3T
than a female catheter, so as to be adapted lor attacking strictures of the bulb
and the membranous portion. Dr. Randolph assures us that Dr. Gibson has
succeeded with it in cases in which no other method could have been
successful. But every one must see that the cutting edge of either Dr. Phy-
sick's instrument or that of Dorner, no matter how skillfully used, will enter
more often into the thickness of the canal than into the middle of the obstacle,
and in many cases will leave the stricture wholly untouched. Dr. Despinay,
who approves of incisions only in cases of contractions of the urethra of a bri-
dle shape, in its anterior part, about the fossa navicularis for example, advises
that they should be executed with a straight, very narrow, and probe-pointed
bistoury. The object can evidently be better accomplished by the bistoury
contrived by Bienaise or M. Civiales' small sheathed urethrotome. The advan-
tages of this plan of operating over that pursued by Dr. Physick no one
can dispute. The incision being made by a lateral effort, and from behind for-
wards, gives rise to no exposure to a false passage, as that one does which is
made from before backwards, beyond the conducting instrument. Dr. Ash-
mead acting upon the same idea as M. Despinay de Bourg, has had an instru-
ment made which is a concealed bistoury like that of Brother Come, the sheath
of which extends to a point, blunt or buttoned, to go through the impediment;
its blade cutting only for an extent of six or eight lines near its extremity, so
that when it is opened it incises only the strictured part, which is thought by its
inventor adapted for any region of the urethra. Others, M. Dzondi first, and
afterwards M. Amussat, have contrived a sort of drill with four, six, or
eight cutting edges, or crista, parallel to its axis, projecting for half a line, or
a line at most, on the circumference of its vesical end, which for a distance of six
or eight lines should be somewhat enlarged. The intermediate grooves are filled
up with tallow. It is enclosed in a straight canula, by which we are enabled
to carry it down upon the obstacle. When it reaches this part we begin to
push; it quits its canula and enters the stricture. The tallow either melts or
is pushed back by the resistance. The little edges stand out isolated, and
cut the constricted circle, like scarificators, in different directions. Then it is
drawn out, a catheter or flexible bougie immediately enters its place, and is
left in for twenty-four hours at least, and renewed from time to time
until the cure is accomplished. In order that such an instrument may pene-
trate, the stricture must not be complete, for the beak which does not cut, and
which has to pass first, is nearly two lines thick ; of course the introduction of
a pretty strong bougie cannot be very difficult, and we seek in vain for any
justification for the performance of urethrotomy. The same reproach lies against
Dr. Ashmead's instrument and M. Despinay's procedure ; but with this dif-
ference, however, that as it may assume the form of a bougie, or a stylet, the
latter urethrotome will traverse the impediment after the manner of a catheter
and will only divide it secondarily by an after stroke. It combines the qual-
ities of an urethrotome with that of a conducting catheter, or a bougie for dila-
tion ; it can bear upon one point only, or it may cut several successively, and
at different depths, at the pleasure of the operator.
It is this instrument consequently which answers best, whenever it is abso-
lutely requisite to practise this method of incision.
108
858- JTEW ELEMENTS OF
§ 4. Concentric or External Incisions.
Strictures of the urethra occur so frequently and give rise to accidents of
so serious a nature, that the genius of surgeons is untiringly employed to dis-
cover some remedy, and the most dangerous and painful methods have beea
proposed for their removal. Planque has given us the case of a surgeon
who fearlessly opened an urethra from one end to the other, so as to cauterize
and cleanse its interior, which he after re-united by means of several twisted
sutures, upon a catheter, and cured his patient ; which in Solingen's time was
the method in use at Livourne. Instead of thus dividing its entire length,,
many surgeons determined upon merely incising the strictured part. J. L. Petit,
an advocate of this method, permitted the wound to heal upon his S shaped
catheter, whilst, according to what M. Dolivera says, Lassus after a similar
operation replaced by a gumelastic catheter in 1786. M. Levamier of Cher-
bourg, who was stopped by an almost entire obliteration of the canal, fearlessly
revived the procedure of Petit and Lassus, and his boldness was crowned with
complete success. But that in our own time several surgeons had chosen to
adopt the same operation, and had striven to renew the popularity of a method
in France almost forgotten, a few words of mention would have sufficed for
it. But for some years past it has been too often attempted for me to pass it
by in silence.
The Method of Operation. — MM. Eckstrom in Germany, Arnott in England,
and Dr. Jameson in America, who Have derived marked advantages from the
operation, perform incision of the urethra according to the following rules z
A staif or catheter with a groove in it, is passed down to the obstacle and held
there by an assistant ; the surgeon raises the testicles and stretches the parts
with his left hand ; makes with his right a large slit (buttonhole) on the perineal
wall of the passage with a very sharp bistoury ; strikes upon the staff; with-
draws it a little, then endeavors to find the continuation of the urethra at the
bottom of the wound, at the same time that the patient makes an effort to uri-
nate ; attempts to pass into it a stylet or grooved staff," which he uses as a di-
rector on which to extend the incision backwards for a distance of some lines
beyond the stricture ; and he concludes the operation by leaving a catheter in
the canal as far as the bladder, upon which catheter the wound speedily
heals.
Where the obliteration is very complete, or it is very difficult to discover
the opening, we are advised by M. Groninger to cut at random almost as far
as the prostate ; to plunge either a narrow bistoury or a trocar through this
gland into the bladder, so as to create an artificial canal, afterwards to be
kept open by passing into it through the meatus urinarius a catheter to be
left in, on which the w^ound is to heal. Mr. Cox, who advises the same thing,
quotes a case in support of it which he looks upon as quite conclusive, but
which in fact merely shows how far the rashness or blindness of some surgeons
may be carried. In fact the urethra is never completely closed in an organic
stricture. Even supposing that the simple slit be sometimes indispensably
necessary, and that forced catheterism should not receive a preference over it,
when passing a bougie becomes absolutely impossible, it may at least be as-
OPERATIVE SURGERY. 859
SBrted that such an incision as this ought always to be sufficient to enable any-
well informed man to discover the continuation of the canal. It would assuredly
be much easier, more rapid, and less dangerous to puncture tlie bladder, than
perform the operation advised by MM. Gwneger and Cox, and twenty times
less painful. Besides, I doubt very much whether any French practitioner of
the present day will find it necessary to imitate this conduct, and even
whether they will not constantly avoid making even the simple slit in the peri-
neum.
§ 5. — ^Dilation.
The treatment of stricture of the urethra by dilation, is the oldest of which
we possess any knowledge, and for a long time was the only one in use.
Leaden bougies formerly used and cried up as new some years ago by M.
Horzberg ; those made by Schmidt of a composition consisting of an alloy
of tin and lead, although very flexible, were too hard and weighty to be borne
by the urethia without inconvenience. Bougies made of wax and of gum-
elastic have alone been retained in practice.
The former of these instruments were formerly constructed of several
substances, and were particularly extolled in 1551 by Lamna, and by Daran
in 1745, under the name of emplastic bougies. Since the possession of me-
dicinal virtues has been denied them, and that they have been esteemed on
account of their mechanical properties only, red, v/hite, or yellow wax made
flexible, has been substituted for the various component compositions of a
resolvent, astringent, or desiccative nature. The only qualification now looked
for in them is that of suppleness, softness, an inability to melt in the organs,
a capability of moulding themselves to every inflexion of the canal, and an
absence of all brittleness whatever. The leaden wire by some persons intro-
duced into their centre to add to their solidity is useless. A delicate and
slender piece of cat-gut is better, if we are absolutely determined not to use
those which are made of emplastic cloth. The second variety, the gumelastic
bougie, which is more soft, supple, and flexible, and still less irritating than
a wax one, has the inconvenience of distressing the urethra more by its very'
elasticity, and its disposition to straighten, particularly if it be of any size;
whence it follows that as mechanical agents they cannot be substituted in
every particular for emplastic or sear cloth ones, as Soemmering and most
authors of modern times have asserted. Each is met with under various shapes.
Some are cylindrical, some swelled, some conical, &c. Conical bougies grow
larger as they penetrate, and therefore are advantageous in dilating the canal
more rapidly and not bending up as readily in it; but they have the disad-
vantage on the other hand to tend to escape from it ; to fill it up too accurately,
and consequently to distress it much towards its base ; moreover, if the in-
struments are too long they project into the bladder before tliey act suitably
upon the strictured part. It is necessary that their point, beginning very thin,
should not be more than twelve or eighteen lines from the body of the cone,
and that they should afterwards be cylindrical up to their head ; it being
remembered that no bougies below Nos. 8 or 6 require this modification,
which would enfeeble them to no purpose.
The bougie a ventre^ or which bellies or swells out, will often deserve a
860 NEW ELEMENTS OF
preference. The fusiform (spindle-shaped) enlargement of its posterior fifth
when it is long enough, is no obstacle to its being made conical on that side,
and the sensibly less considerable bulk of its stem, causes it to concentrate
almost all its efforts upon the stricture, distress the urethra very little, and to
be kept in without any difficulty. Led by this idea, M. Desruelles has pro-
posed to substitute for a bougie a metallic canula an inch or two long, to be
left in the strictured part, after being carried down by the assistance of another
instrument, and so as to be kept outwards by means of a string. But the
swelled bougie is better ; it allows us to carry the dilation to any extent we
will, and gives less pain than conical instruments.
The mode of action of bougies upon stricture has not always been viewed
in the same light. It is now only conceded that they cause ulceration and
dilation. This must evidently be erroneous. The eccentric compression
which they cause, bringing about interstitial absorption, may, whilst it distends
and obliterates strictures in the urethra, remove the phlogosis which so often
keeps up their existence. The radical cure which they produce, oftener than
from the testimony of some authors, one would be inclined to believe is
indeed explicable only by this remarkable fact. This leads us moreover to
think that medicated bougies have probably been wrongly rejected entirely,
and that their topical action is perhaps not so despicable as it has not been
well understood.
Ulceration. — Those who have adopted the method of ulceration, rest
their argument on this ground, to wit : a stricture which is merely di-
lated cannot fail to return as soon as the use of the dilating agent is dis-
pensed with ; whereas, if you do induce a loss of substance, you must obtain
a permanent enlargement of the canal. Home recently, in professing a similar
doctrine, has committed a double error. In the first place relapse is not
inevitable after dilation ; in the next, ulceration induces a loss of substance
whose very cicatrization will reproduce stricture with much greater certainty.
There is moreover nothing to prove that it really can be produced at will. A
bougie forcibly introduced into the infundihulum of a stricture, or pressed
down on the centre of the circular constriction, irritates and dilates sooner,
but does not ulcerate and rather excoriates the part.
Dilation. — The medicinal effect of bougies, to which we shall probably at
some future day return, being for the present laid aside, the only thing of im-
portance to be studied is their effect of distension in its different degrees or
under its different aspects. It is a sure and almost an unfailing effect, and
yet attended with the serious inconvenience of being kept up with unequal
constancy, and of acting merely as a palliative to the evil instead of curing it
radically in most of the patients who submit to it.
Still to these objections it may be replied that their weight has been over-
rated ; that strictures which consist neither of frena nor valves, nor salient
cicatrices, nor of vegetations of any kind whatsoever, but which depend on
pure and simple thickening or phlegmasia of the mucous membrane and sub-
jacent organic layer, sometimes yield beneath a well-directed dilation;
and lastly, that it suffices, in order to guard against relapses, to pass a bougie
at first tivery month, then every two months, three or four months, and keep
it in for some hours; a precaution which must be the less annoying to the
patient as he can do it very well for himself.
OPERATIVE SURGERY. 8W
Method of Operation, — la a firm stricture, passing a bougie is not always
an easy matter. If it is too fine it bends up before the least obstacle. It is
easier for it to pass if it be somewhat larger. Cat-gut ones, which are stiffer
and possess more strength in a small compass, here offer some advantages.
M. Delpech advises us to flatten and chew the point a little so as to change it
into a sort of supple and delicate pencil ; he then passes it through the obstacle,
takes it out at the end of two hours, carries in a larger one, which he removes
after a like interval and puts in another, and on the same evening, if he thinks
it practicable, replaces that by a bougie or gumelastic catheter. The swelling
of which they are susceptible makes them in such a case dilators of precious
value ; but as they untwist, soften, and grow knotty, if we delay changing for
more than two or three hours, we run some risk of their breaking or scraping
the urethra.
Small Catheters, Hollow Bougies. — It is also frequently most convenient
to begin with a very small catheter or a hollow bougie. The stylet with
which it is provided should be well curved up to the beak, and as strong as
possible. The whole is then introduced into the bladder according to the
rules of catheterism. Besides which it is prudent to be provided with
catheters, bougies, and cat-gut bougies in one's case, so as to be prepared to
try them one after the other if it be necessary. For the patient there can be
no fixed position. Sometimes he must be allowed to stand up, sometimes to
sit down, and sometimes to lie horizontally upon the bed. The penis, which
in general is raised, requires in other cases to be slightly lowered and drawn
forward. The patient, guided by the sensation he experiences and the resist-
ance wdth which he meets, will succeed sometimes where the most skillful
surgeon had failed. The want of success in a first attempt is no argument
against its renewal. A thousand peculiarities, of which practice alone can
make us aware, may oppose themselves to our success at first, and permit it in
a moment afterwards. Upon the whole the procedure is very much the same
as that for performing catheterism. The penis is held in the left hand, the
bougie is pushed on with the right. The most delicate instruments most
readily catch on the bottom of the lacunas of Morgagni, or of the slightest
plait in the canal. The moment that any resistance is felt, the bougie is to be
turned as an axis between the fingers after having been withdrawn a few lines,
and is again to be pushed onwards (as it is being turned) to the obstacle. A
cul-de-sac, a fold, a wrong direction, a rugosity, an elevation caused by the
stricture itself, may arrest its progress. It is then particularly that it must
be made to advance gently; it must be drawn towards the operator; its in-
clination is to be varied ; it is to be turned round in the fingers and its advance
favored by means of the fore-finger applied to the perineum. It is known to have
entered the stricture when, not advancing furtlier, it shows no disposition to
recede and seems to be compressed at its point, as it were. We may be very
sure of the reverse, so long as it springs back on relaxing the pressure, and
offers no resistance to any attempt to withdraw it. A person of experience
will never be deceived, and will feel better than he can describe the diff*erence
which there is between a bougie which has engaged in a stricture, and one
which is merely stopped in the urethra.
In the former case, the excess of its bulk alone preventing its passing, we
have but to replace it by a smaller one, or else fasten it at the point at which
Bd2 new elements of
it has entered. In the second, the attempt is to be renewed in every possible
way, by taking bougies of larger and smaller size, and of different forms and
shapes. As a last resource, the bougie may be fastened at that part of the
mrethra to which it has descended, provided its extremity be not turned up
into a sort of brush. It is by no means an impossible thing that by so doing
it may of itself clear the obstacle ; and that in half an hour's time nothing may
be easier than to make it advance considerably. This conduct which has been
for a long time pursued at the Hotel Dieu, at Paris, has produced numerous
and oftentimes unexpected instances of success. If the canal appears to be
too much irritated, too painful, if it bleeds abundantly or is spasmodically con-
tracted, we must suspend the operation and return to it again when these symp-
toms shall have subsided. Emplastic bougies previously curved at the point
can, it is true, be no longer rolled between the fingers ; but they accommodate
themselves better to the direction of parts, and in certain cases overcome ob-
stacles which had resisted all the others. That which seemed to be impossi-
ble, is sometimes rendered easy by bathing the penis in cold water ; warming
the instrument before it is introduced ; besmearing it with cerate moistened
with oil ; or by charging it with some ointment containing opium or belladonna.
A long probe-pointed stylet, having a ring at the other end, introduced by a
rotatory motion, has succeeded with me in many difficult cases quite as weU
as with MM. C. Bell and Vanvelsuner, who proposed it in 1814 and 1821.
The button at its end is an excellent means of clearing the most irregular
strictures, and as M. Segalas has pointed out, it allows the extent of the con-
traction to be measured.
I now suppose the bougie to be introduced. To fasten it in, it is only neces-
sary, when it is an emplastic and swelled one, to bend the end near the glans
penis in the form of a hook, or of a ring. When cylindrical or merely conical
it must moreover be capped by a condon, or bag of fine linen, which encloses
the penis at the same time. Elastic bougies require similar precautions
to those given when we were speaking of catheters permitted to remain in the
urethra.
The time which the former are to be allowed to remain in, varies accord-
ing to a variety of circumstances ; according to the sensibility and irritability
of the canal ; to its being otherwise healthy or diseased ; to the degree of suffer-
ing experienced by the person ; to the date and state of the stricture, whether
old or recent, slight or serious ; and lastly, to the etfect which it is intended
to produce. It is rare, however, for it to be less than half an hour, one or two
hours, or more than twelve or eighteen hours, which is usually about as long as
the patient can endure it without too much suffering. If the want of making
water is very acutely felt, and the urine cannot escape between the walls of
the urethra and the foreign body, conical bougies have this advantage more,
that by withdrawing them a little the urine passes easily, and they can be re-
placed with facility at the same distance which they were at before. Flexible
catheters, either conical or cylindrical, are valuable in this respect, for it is not
necessary to change them so as to allow the bladder to be voided, and there
are persons who cannot retain their urine for more than an hour, or even as
iong.
Neither can there be anymore certainty as to the time of each application.
We are sometimes obliged to wait two or three days, whilst in other cases the
OPERATIVE surgert. 86S
organism gets so rapidly accustomed to it and the patient is so little inconve-
nienced, that it may be repeated next day. At each new introduction,
we employ an instrument of rather larger size, as soon as that last used begins
to traverse the urethra freely ; but conical bougies being thicker the deeper
they are made to penetrate, do not so absolutely demand this change. As the
cure progresses, the sittings approximate and are made to last longer. As a
principle, it may be asserted that every stricture which may be traversed by a
bougie, however delicate, is curable by dilation. The treatment, which is pro-
longed always in proportion to the hardness and resistance of the stricture, the
susceptibility of the patient to impressions, and the facility with wliich he may
be managed, is sometimes not concluded until the end of two or three months ;
but I am certain from an ample experience of facts that we may, in most per-
sons, at the end of twenty days or a month, succeed in restoring the canal to
its natural dimensibns, particularly by the use of conical bougies. I have even
succeeded in obtaining such dilations in the space of six, eight, twelve or
fifteen days, in patients whose strictures had lasted for years ; and in some
also who had been previously treated either by caustic or bougies, but in whom
the cure had remained incomplete. I have no faith in the danger to which it
is said to be liable, or in the pain which by some authors it is said to produce*
Skillfully applied, I have never seen a serious accident result from its use. The
mucous or blenorrhagic oozing which it sometimes induces, almost always dis-
appears of itself after continuing some days.
The fever preceded by rigors and ending in perspiration, like an intermit-
tent, which is caused in certain cases, has in it nothing alarming. The ner-
vous sensations, engorgement of the testes and chord, are occasional oc-
currences, which are no oftener caused by using bougies than by simple
catheterisra. A patient, however, whom I performed it upon at La Pitie
was attacked with symptoms which it is proper to relate. After several at-
tempts, a conical bougie had been passed. One morning this man was attempt-
ing to replace it of his own accord, in which he could not succeed, and made his
urethra bleed. An attack of fever which had attended the first trials, recur-
red, lasted for three days, and yielded on the fourth, to be succeeded by a
most violent and painful arthritis of the right tibio-tarsal articulation, inv/hich
a prodigious abscess formed, and afterwards anchylosis. This leg had beeR
fractured above the malleoli about six weeks before. Is this a coincidence ?
or is it an effect of the same kind as that which blenorrhagia often pro-
duces ?
The only real reproach which a bougie deserves is this : relapses may follow
its use ; and we are obliged, therefore, to carry the dilation beyond the normal
dimensions of the urethra, not to abandon bougies suddenly, and to continue
to introduce them from time to time for at least several months.
An air dilator may be formed of a little fusiform, or a cylindrical bag sup-
ported by a stylet and carried through a flexible tube, which is to be introduced
flaccid into the stricture, and afterwards inflated with the breath; which Du-
camp says ought to supersede the swelled bougie, and offers the important
advantage of distending the stricture powerfully without at all acting upon
the rest of the passage.
We now however know that this statement is not correct ; that the little
bladder necessarily moulds itself upon the urethra, and presses quite as much
864 NEW ELEMENTS OF^
on either side of it, as upon the stricture itself. Mr., Arnott's dilator is not in
reality any better. .M.Castallat showed me another one which consists of a
long canal of fine linen, which is passed down into the bottom of the urethra
by a long flexible stylet. This tube, which ends in a cul-de-sac at its vesical
end and is open and burnished with a ferrule at the other, is intended to receive
little portions of lint or cotton, which are crowded down into the stricture
by means of another stem, so as to obtain a dilation as rapid and as gradual as
may be desired. However great the ingenuity of these contrivances may be,
I doubt whether they will preserve a place in practice. Bougies will, with
scarce an exception, allow the same end to be accomplished, and by their
simplicity deserve that preference which, in all probability, will always be
shown them.
§ 6, Cauterization.
Under the belief that strictures of the urethra depended upon vegetations
and fungus growths, surgeons, about the 15th, 16th, and 17th centuries, acquired
the habit of treating them by caustic. Verdigris, vitriol, savin, &c., mixed
up with emplastic compositions, and made into bougies, were employed for
this purpose. Ferri, Ambrose Pare, F. de Hilden, Rivere, &c., speak of it
as a very general method, and often dangerous, and it is well known that Loy-
seau wa^ bold enough to practice it upon king Henry IV. In the last century,
however, it was scarcely employed, and but for the improvements made in it
by Lemonnier, Wiseman, Roncali, Hunter, Sir Ev. Home, Arnott, Ducamp,
and several other practioners in France, this method, which ultimately became
general, might without any great loss have remained in the oblivion into
which it had fallen. The use of the nitrate of silver, instead of sublimate
and other caustics originally employed, seems to have removed its dangers
and has procured for it the suffrages of many. Since then the demonstration
of the possibility of touching only the diseased part has so completely
satisfied men's minds as to render the practice, in a measure, a common one.
It would, however, be incorrect to suppose Ducamp the original author of
these changes. Bougies for taking an impression of the stricture were used
as early as the 16th century. F. Germain and L. Mazell expressly recom-
mend that the seat and form of the stricture be ascertained by the beak of
an emplastic bougie ; that it be withdrawn and that a layer be removed from
its point, for which a caustic material is to be substituted, and then that it be
carried down again, thus armed, into the strictured canal. The procedure
of Sir E. Home, which consists in fastening a fragment of lunar caustic upon
the point of a bougie for the purpose of passing it down to the stricture,
evidently differs a little from that of Germain or Mazell. In like manner
A. Pare anticipated John Hunter in inventing a canula for protecting the
canal, whilst the bougie armed with the caustic is being introduced and allowed
to act. As it is remarked by M. Dezeimeris, Lemonnier was also acquainted
with the method of seeking for the impediment, and taking an impression of
it in wax, before proceeding to apply caustic to it. F. Roncalli moreover had
employed the very same caustic as Hunter, or the same procedure as Pare, ever
since the year 1720 ; and the practice of Wiseman was so far from being
given up, at the period of the experiments of his countrymen, that in 1755
OPERATIVE SURGERY. 865
AUies complained of its proving so frequently fatal at Paris. In spite of
the remarks and modifications of MM.Aberdom and Wathely, the method
of Sir E. Home, adopted in France in 1818 by Petit, was so violently opposed
by Rawley and Carlisle, amongst others, that even in England it labored
under powerful prejudices. The work of Mr. Arnott in 1819, founded upon
principles similar to that of Ducamp, produced scarcely any sensation in
London; any more than that of M. Mcllvain, published in 1830. will do
towards establishing the use of potassa.
Cauterization from before backwards, with or without a protecting canuia,
has, since MM. Arnott and Ducamp made their method known, almost
entirely disappeared from practice. If any. should still be disposed to
attempt it, tlie armed bougie invented by Messrs. Home and A. Petit being
flexible, ought to be preferred for strictures near and beyond the bulb. If it
be pushed forward rapidly, it is difficult for the caustic wliich occupies its
beak to touch the walls of the urethra before it comes to the funnel-shaped
constriction; it is then pressed down, a little of the nitrate melts, and in
about a minute it is withdrawn. When the obstacle is not so deeply situated,
Roncalll's or Hunter^s canuia maybe employed without inconvenience. Mr.
Chas. Bell and Mr. Shaw thought that the beak of a metallic catheter, curved
or straight as the case might be, with a central aperture if the obstacle is
central, if lateral an opening on one side, v/ould answer the indication better
by giving an opportunity of carrying down a piece of caustic and projecting
through one of these holes, either with a bougie, a long forked stylet, on any
other appropriate instrument.
Lanteral Cauterizaiwn, which has lately attracted so much attention, re-
quires more caution and is performed by divers procedures, all belonging to
the same method. The apparatus of Ducamp for this purpose, consists, 1st,
of an exploring catheter, made of gumelastic and graduated, which is in-
tended to ascertain the depth at which the impediment exists ; 2d, of a bougie
for taking an impression, which is another graduated stem, having a certain
quantity of ductile wax at its extremity; Sd, ofa conducting catlieter, also
graduated and flexible, fitted at one end with a platinum socket, and enclosed
in a silver tube at the other; 4th, of a caustic holder, consisting of a small
platinum cylinder, having a slit hollowed out upon one of its faces, a transverse
pin towards its root, so as to prevent it from going beyond the beak of the
conductor, and also a flexible stem with which it screws, and wliich is
continuous on the other side with a metallic stylet armed with a ring.
The Method of Operation. — The positions of the patient and the surgeon
are the same as for catheterism or the application of bougies. The little pla-
tinum cup is filled with fragments of caustic before it is screwed upon the
flexible stem. Holding it then in the grasp of a good pair of forceps, it is
placed over a candle or a wax light, the flame of which is steady, so as slowly
to melt the caustic, and not allow it to swell up, which happens when it is
heated too rapidly, or when the cup has not been cleaned or dried. It tiien
remains only to make the whole smooth by removing the roughnesses and ele-
vations which may have formed upon it with pumice stone, or the edge of
some cutting instrument. We are then ready to begin the operation, after
having accurately determined with the exploring instrument the depth at
109
866 NEW ELEMENTS OF
which the obstacle is to be found. The first thing to be introduced is the
impress bougie. It is held firmlj for a moment against the stricture ; the
wax melts, fills it, and enters the narrow part. It is withdrawn and the size
of its lengthened point gives the measure of the diameter to be gone through,
whiUt the cast on the wax should show whether the stricture is central, circu-
lar, or if not, in what part of the urethra it exists. We then pass down the
conductor to the same depth, where it is kept fixed with the left hand ; then
we take hold of the ring of the caustic holder in our right hand, and push it
in such a way as to make the platinum cylinder loaded with nitrate pass out,
by turning the cup towards the diseased side ; in a word, by making it enter
the diseased circumference. The wings of its pin stop within the socket of
the conductor. It is left for a minute, or only half a minute, in contact with
tlie tissues. Having drawn it back again into the catheter, we withdraw the
whole apparatus and the operation is at an end. By this procedure, if there
be more than one stricture existing simultaneously, w^e cannot attack that
which is farthest off, until we have successively destroyed all the others.
The porte-caustique being straight and supported by a very feeble flexible
stem, it is both dangerous and difficult to enter the curved portion of the
urethra. Besides which, the fluids secreted by the organ very often dissolves
tlie nitrate before it can enter the stricture.
One of the first persons who endeavored to do away these inconveniences
was M. Lallemand. His caustic holder, which ended in a knob or button of
but one piece, with the stem which makes it move, is straight or curved accord-
ing as it is intended to penetrate a less way or very deep, and is enclosed in a
sheath or catheter of platinum, having the same direction and more diameter
than is necessary for it to apply itself accurately upon the cylindrical or
swelled portion of the stylet. A sliding ring, armed with a press screw, em-
braces the conducting catheter or sheath. The stylet has at its other end a
lenticular button or a nut, which is not put on until after the instrument has
been introduced from behind forwards into its sheath or canula. In drawing
it towards one's self, the small enlargement at its head completely closes the
beak, and makes the vesical end of the catheter a blunt point. It is carried thus
closed as an explorer into the bladder, so that we maybe certain whether there
is or is not more than one stricture. If there be several, we may begin with
the last as well as with the first, and either apply the caustic from behind for-
wards, or vice versa, to one after the other, or all at one sitting. AVhen it is
placed in contact with the first stricture, the sliding ring is pushed down to the
meatus, so as not to lose sight of the distance of the stricture. By drawing
the sheath towards one's self, the cup of the stylet is disengaged, and falls
covered upon the altered tissue. To close and withdraw it, to push it for-
ward or bring it back to the other strictures, it is nearly indifferent whether
we move the sheath upon the stylet, or the stylet upon the sheath, by pushing
the one or by drawing back the other. In this apparatus it is necessary to
have several stylets, if it be a curved instrument ; because, being wholly me-
tallic, they cannot turn upon their axis within the canula, and their cuvette or
cup necessarily faces a fixed point. We must have them, therefore, with
cups on their concave edge, others with the cup inferior, and others again in
which it is placed laterally. They must also be of different dimensions, with
. slicaths likewise of various caliber.
OPERATIVE SURGERV. 86r
M. Segaias, wishing to preserve the advantages possessed by the instru-
ment of the professor at Montpelier, without relinquishing those in Ducamp's
apparatus, uses a stylet composed of small chains at its deep part, resembling
the lithotritor of M. Pravaz, which easily performs all the necessary rotatory
motions, and can turn its cup to all the different points of the diseased circle
successively. He encloses it, armed with its sheath, in the conducting
catheter of Ducamp, so as to enable it to penetrate to the first stricture.
M. Pasquier has caused a rim of a circular shape to be placed behind the
cuvette or cup of the porte-caustique instead of a pin ; so that it might not be
necessary to turn the stylet containing the caustic and conducting tube at the
same time, as in the instrument of Ducamp. Some other modifications have
been adopted by this surgeon, which being of trifling importance, may be
retained or rejected with indifference. Among others, he has done away
with the bougies for taking impressions, used in the primitive method, and
with the exploring bougie ; and prefers, according to M. Racine, to com-
mence the treatment by the common bougie and by dilation, so that the caus-
tic may be applied first upon the stricture which is furthest off. Some
persons have thought that the stylet might be made of still easier management
by lengthening its outer extremity — which is of metal — by cutting it angu-
larly instead of its being circular, so that the pressure screw of the open ori-
fice of the conducting canula may the better adapt itself to it ; and have
attempted to do away with the need of this screw, by terminating the stylet
in a forceps head, one of whose branches is free, and provided with transverse
grooves which fasten it conveniently in the square opening of the wide end of
the sheath, whilst the other is continuous with the stylet itself; nor have I
thought these slight alterations were to be altogether despised.
The stylet to which I give the jweference, without however attaching any
great importance to it, is made of silver, with a platinum cup, has no rim, and
has a button at the end like M. Lallemand's. Its free extremity is a sort of
watch-spring, from twelve to fifteen, lines long; it fits into the immovable
branch of the forceps head I just spoke of, in such^a way as to be held there
by a pressure-screw, or to be withdrawn at pleasure. Its sheath is the same
as the flexible canula of Ducamp, in which I do not enclose it from behind
forwards, until I have curved it like the stylet of gumelastic catheter, when
I think it necessary. The forceps head being placed in, we have only to pull
upon it to close the instrument; and then to apply the button or knob at its
cauterizing end over the deep opening of the conducting canula. Its flexibi-
lity permits me by curving it before the operation to turn the cup upwards,
downwards, or on one side. Its head prevents it from making a falee passage,
and protects the caustic against the moisture of the canal. To make it
advance, it is sufficient to approximate the two branches of the forceps head
with the thumb and fore-finger of the right hand, to pass that wliich is free by
the side of the other into the wide orifice of the canula, and push them on
together whilst the left hand holds the instrument firm in the penis.
Estimate of .the Method, — The principal defenders of tlie cauterizing of
strictures lay great stress upon the need of determining, in a matliematical
manner, not the depth merely, but the length, shape, thickness, and situation
of the stricture. About the first of these points there can be no difficulty.
'^68 NEW ELEMENTS OF
Any blunt instrument will answer the purpose iind give as much information
as the explorer or, impression bougie of Ducamp.
It is not so, however, with the second point. The emplastic or gumelastic
bougie, pointed with doctile wax, which the same writer advised to be passed
down upon all the strictures at once, with the idea of getting several casts at
one time, is of not the least use whatever. A long stvlet with a cylindrical
head is of infinitely more certainty. This is passed down to the obstacle
either bare or enclosed in a blunt catheter like the common stylet. The
figure which then corresponds with the meatus urinarius is noted, unless the
meatus be at the top of the catheter. It overcomes the stricture, which, how-
ever, impedes its exit a little, by which mechanism it becomes very easy to
measure its extent, for the point of departure and that of its return outwardly
may both be marked.
To settle its thickness and shape gives more trouble. Ducamp's impression
bougie is a deceitful instrument which deserves to have no reliance placed
up-an it, and is fit only to serve the purposes of empiricism and imposture.
When it gets into the urethra, the wax yields as readily beneath the action
of a fold, a spasm, or a momentary flattening of the canal, as beneath that of a
true stricture, and I have never known a practitioner of distinction who dared
to use the nitrate of silver upon no other authority than this. How many
urethras have been needlessly cauterized, because of supposed constrictions,
originating in Ducamp's bougie being withdrawn distorted in shape .^ M.
Pasquier v/as therefore quite right in proscribing it, and I think it is an in-
strument which should be banished from surgery. M. Amussat has proposed
as a substitute for it a straight canula, which has a stylet, whose end has a
liead which is nail-shaped, or of the shape of a lentil. This head closes the
opening and forms the beak of the instrument, but is so arranged that the
handle is inserted a little without the centre of the terminating plate. When
the canula is in its place, it is held or caused to be held motionless with one
hand; and the stylet pushed forward with the other. The rasp clears the
obstacle, it is turned upon its axis; immediately its cutting edge passes
laterally the level of the sheath ; on being withdrawn, it rakes the cor-
responding wall of the urethra, which, if it meets with nothing, must be in a
sound state; on the contrary, if it encounters a frenum, a projection, or the
morbid tissues themselves, which arrest it, and withdraw it/rom the sheath,
it is diseased and strictured. This instrument which, except that it is straight
instead of curved, does not differ much from Fare's urethrotome, is not less
defective than Ducamp's bougies, is still more dangerous, and could only
succeed in very large strictures.
We shall, by and by, discover what necessity in reality there is in practice
for any of these precautions.
Amid so many contrivances, which one are we then to retain } The appa-
ratus of M. Lallemand would evidently be the best, if it were indispensable
that every stricture should be passed successively, when several exist. M.
Scgalas's, if it were less complicated, would possess equal advantages. But
I must, after all, give the preference to that of Ducamp, altered by M. Pas-
quier, or as I myself use it, if one must be adopted to the exclusion of every
other. But it is with cauterizing the urethra, as with every other operation ;
OPERATIVE SURGERY. 869
to a skillful hand ail instruments are good; to an unskillful one, there are
none which will be found convenient.
Effects of the Caustic. — The nature of the eftects produced is always the
same, whatever may have been the procedure adopted. Whilst the nitrate is
bare in the Urethra, the patient feels pain and a stinging or burning sensation,
which in some is obtuse, in others very acute ; and which lasts for a longer or
shorter time afterwards. This difterence depends on several causes ; some
of the cerate, oil, or tallow, maj remain round the caustic, and bjits viscidity
prevent It from acting; or the hardened tissues of the strictured circle,
may have lost nearly all their sensibility : on the contrary the nitrate may
touch some sound part ; it may spread behind or before the stricture; or the
canal may be at the time the seat of a morbid sensibility and irritation, more
or less developed. When there is no false passage, nor any discharge, the
pain speedily subsides usually, and the blood does not always make its ap-
pearance. However a bath, either immediately or in the course of the day,
is always useful to guard against accidents. When the stricture extends
very far, or the cauterizing has been severe, it may happen that swelling and
congestion may cause retention of urine ; which is induced also in other cir-
cumstances by flakes of matter, or eschars, wjiich are entangled in the centre
of the obstacle. They are speedily got rid of by a fine bougie, a warm bath,
and tepid injections. If we are threatened with inflammation, we must apply
leeches to the perineum. On the morrow, or the second, or third day, flattened,
grey, blackish, or whitish flakes begin to issue from the urethra with the urine,
the exit of which they again render very painful. However this expulsion is
not always present, but sometimes wholly wanting, notwithstanding that the
caustic may have had a very powerful eft'ect. As soon as irritability has subsided
and the sensibility and tenderness of the organ permits, say in three, four,
five, or six days, we recommence its application. Some persons, and I think
tliem right in doing so, pass in a bougie for a few minutes, from time to time,
during this interval. Others again resort to dilators only after the destruction
of the stricture, which in that case demands from four or six to thirty or forty
introductions of the caustic ; and a treatment consequently of from two weeks
to three or four months.
The Theory. — Tlie last question which remains for solution, is tliat of
the advantages derived from cauterization. Its advocates, with Hunter at
their head, maintain that mere dilation is but a palliative means almost in-
variably followed by a return of the disease. That to obtain a cure which
shall secure against a relapse, we must not merely mechanically remove and
dilate the stricture, but that we must destroy and corrode it, as is done by
caustic ; after which bougies come in to smooth the surface and complete the
cure. To this the opposers of the treatment reply, that the loss of substance
which the caustic causes must leave a hard, elastic, and generally a rugous or
uneven cicatrix, which will almost certainly bringback the stricture; that on
this ground cauterization is even more subject to relapses than dilation ; ai^tl
that being incomparably more dangerous there appears no reason for giving it
the preference. That to enable it to act at all the caustic holder requires a
canal a line in width, which is a diameter that will always allow of the use of
a bougie, and that this latter instrument will often pass where the caustic cup
cannot enter. ■ Arguing from the first of these objections they ask M'here is
870 NEW ELEMENTS OF
the advantage of caustic since bougies are applicable wherever it is applicable,
and that they moreover must precede and follow it in almost every case ?
These arguments never were and never could have been triumphantly replied
to by those to whom they were addressed. To destroy force, we must take
another view of the mode of action of caustic.
Nitrate of silver alters the vitality of the parts which it touches much
more than it consumes them. In the urethra its action is to extinguish a
chronic inflammation which produced a stricture, and by which it is almost
always maintained and established, just as it extinguishes many cutaneous
phlegmasijE, tetter, erysipelas, the pimples of small pox, &c.;as it checks the pro-
gress of certain anginas, aphthae, ophthalmiae, &c. By this agency it is, and not
by causing ulceration, that it dries up old discharges, the seat of which is
sometimes before, sometimes beyond the bulb of the urethra; that it has been
so successful in the hands of M. Lallemand, among others, in many aifec-
tions quite independent of stricture. But according to this hypothesis it
ought to be our aim, instead of wishing to cauterize, ulcerate, and destroy, to
effect mere touching of the parts. We should consider the nitrate of silver
eriereiy as a topical application, intended to sufflaminate the morbific cause ; to
bring about resolution of the lardaceous congestion and the absorption of the
fluids effused or accumulated in the meshes of the mucous membrane and sub-
jacent tissues ; not to regard it as a true caustic. Therefore potassa, which M.
Whately advises us to substitute for lunar caustic, is clearly a pernicious agent,
which ought never to be employed in practice. Upon this principle we should
explain the good effects derived from the medicated bougies of the ancients,
and also how it is possible for every species of cautery used, to have succeeded.
With this idea the use of nitrate of silver becomes extremely simple.
Impression bougies become useless, because all that is required is to put it
into the stricture with some instrument or other, without troubling oneself
whether it is shorter or longer, above or below, provided that in dissolving-
it spreads at once over the whole circumference of the canal. Conductors
perforated outside of the centre of the platinum socket which caps their extre-
mity, in order to separate the caustic-holder from the sound wall of the
urethra, and on the contrary to apply it more accurately upon that which is
diseased, become equally destitute of importance. Bougies and caustic then
'hold the first rank ; the first, to dilate and enlarge; the second, to cure the
structure and to give to the tissues the original qualities of their normal
state. Unless I am greatly deceived the treatment of the great majority of
organic strictures of the urethra, may be reduced to the following rules : first
to dilate them ; to cauterize them for the first time only after four or five
applications of the bougie ; to recontinue the dilation ; to apply the caustic a
second, a third, and a fourth time, at varying intervals ; and after having
restored the canal to its utmost diameter, to return to it once or twice more
to extinguish the last traces of inflammation and morbid irritation which may
have remained behind.
§ 7. Abnormal Dilation of the Urethra,
in the case of a patient affected with incontinence of urine, whose urethra
was considerably dilated, it occurred to M. Habort to excise partly the
OPERATIVE SURGERY. 871
walls inferior after which he re-united the wound by means of suture, and
thus succeeded in restoring the vesico urethral functions.
SECTION IV.
Puncturing the Bladder
It is now so rarely necessary to interrupt the continuity of the bladder to
give issue to urine, that M. Roux and several other surgeons of great distinc-
tion and experience have never encountered this operation. Since the diseases
of the prostate and urethra have become better known, retention of urine is
of very rare occurrence, and when it does happen the accuracy of anatomical
knowledge possessed by most surgeons of the present day, enables them
almost always to overcome it through the medium of bougies or simple cathe-
terism. It may so happen, however, that every other means may fail, and
we maybe reduced to select between forced catheterism and puncturing;
between two operations of equal danger, but the first of which it is not
within every body's power to perform. The second may be practised in three
ways; through the perineum, through the rectum, and through the hypo-
gastrium.
Art. 1. — Perineal Puncture of the Bladder,
Opening the bladder through the perineum, as a means of remedying
ischuria, must, to the ancient lithotomists who admitted no other way of
extracting calculi, have appeared a very simple operation. Consequently it
was the first proposed and for a long time the only one followed. Latta, to whom
Soemmering gives the credit of it, is no more the inventor of perineal puncture
than Garengeot, who claimed fifty years previously. It is expressly
advised by Riolan and Thevenin, and Toilet had performed it in 1681.
Dionis, besides, describes it very lengthily, and proves that it can be per-
formed in two ways.
An incision upon the raphe an inch long, as if for the apparatus major,
permitted a long bistoury to be plunged Into the front of the anus, quite
into tlte bladder ; a catheter to be slipped into it on withdrawing the knife, and
a canula to be left in the wound, through which to evacuate the urine.* But
Dionis thought that it would be better to extend the incision a little out-
Vv'ardly as in Brother Jacque's method of performing lithotomy, so as to save
the prostate. Juncker, Lapeyronie, and Heister, all about the same time
conceived the idea of substituting a long trocar for the bistoury, which tliey
supposed had very much simplified the operation. Thus conducted, it is
reduced to the first period of Foubert's lateral cutting for stone, and is
done in the same manner ; that is to say, they buried the instrument in the
middle of the space which separates the ischium from the raphe, directing a
little forwards and within, so as to fall almost perpendicularly upon the neck
of the bladder. A dread of straying, in passing through so many tissues,
gave rise to the idea of cutting the perineum with a bistoury, and of using
the trocar only after the distended bladder had been felt fluctuating with the
finger, Sabatier has endeavored to cause this modification to be associated
with perineal paracentesis, as Garengeot had indicated it for lateral cut-
872 NEW ELEMENTS OF
ting, the result of which would be to blend the procedures of Dionis and
.Tuncker. But this advice has been generally overlooked. Whilst authors in
France have continued to recommend pure and simple puncturing, surgeons
in England have ever adopted incision; and it seems to have been practised
there in divers manners. Sir A. Cooper, following the steps of Dionis, cuts a
little upon the left of the raphe, depresses the bulb with his left fore -finger,
and then the prostate to the right, whilst with the other hand and a sharp
scalpel, he divides the tissues and enters the bladder. Mr. Charles Bell,
v/hen he thinks it practicable to find the urethra behind the stricture, opens
the canal, as in Cheselden's operation, and says that vie arrive at the urinary
bladder with less'danger in this way. Mr. Brander advises us to come down to
it layer by layer ; but Jones and Dorsey do not see the necessity for so much
caution. Indeed, I do not think that either of these shades of difference has
much advantage over the others. If puncturing with a trocar be more speedy,
it is less sure. The instrument, though safer perhaps for the vessels, the
lireters and vesiculffi seminales, which it would rather separate than divide,
escapes more readily between the different organic layers, and more easily
misses the bladder. With a long and narrow bistoury we must next pass a
catheter and afterwards a canula into the collection of urine. Though less
probable, a false passage is still possible, and a wound of the organs which we
have to avoid is much to be dreaded. Incision, properly so called, is most
ra.tiona], most prudent, and at the same time most difficult. It is rendered
more delicate and uncertain than in lithotomy, because of the want of a
director, which cannot be passed through the natural passages; and this,
v/hether it is attempted to save the prostate as in tlie lateral method, or
whether we penetrate through the urethra. Still, as in such cases the blad-
der is always 2;reatly distended, and its excretory duct much enlarged behind
the stricture, if I am ever obliged to open an artificial passage for urine, I
will confine myself to searching for the urethra, and making a slit in it
between the stricture and the anus, though I should include the top of the
prostate in my incision. The opening thus made would have the double
advantage of o-ivins; entrance to the catheter and canula, which we mii>;ht
wish to introduce into the bladder, and of giving us an opportunity to attend
directly to the diseased canal, from behind forwards. The slit of which I
speak is neither more nor less dangerous than that in ordinary lithotomy, and
is certainly much less so than many other species of punctures ; and, if I am
not deceived, is of such a nature as advantageously to supersede them in all
cases in which a morbid or abnormal state of the perineum does not interfere
to prevent our reaching the urinary passages in this region.
Art. 2. — Puncture through the Rectum.
The projecting cyst which the bladder forms low down upon the rectum
when distended by urine, sufficiently justifies the idea of recto vesical punc-
ture. It is indeed Surprising that it should not have sooner given rise to
it; for by caryini2; the finger into the anus it must have been very often
noticed. Fleurant, who imagined himself the inventor, and Pouteau, his
successor, as a means of preserving the trocar canula in the part, so that
they might not be obliged to perform the operation again if the natural
operati\t: surgery. 8rs
passage was long in regaining its functions, iiad the spoon of tlie canula of
their trocar bent at a right angle with the concave side of its stem. By
this means it becomes, as it were, reversed upon the perineal conduit in front
of the anus, where it is easily fastened in such a way as not to interfere with
the patient's walking or sitting, nor with the alvine discharges. Most of
those surgeons who advise the leaving of a catheter in the wound, have
adopted the instioiment invented by the Lyonnese surgeon. Those who
think with Hamilton that it is better to withdraw it at once, even at the risk
of having to renew the puncture, require nothing but a trocar of the usual
curve. Beyond this, it is a matter of but little consequence whether its
point be flattened and of a lancet shape, or triangular, like that which Mr.
Howship has endeavored to bring into use among his countrymen. Perhaps
a straight bistoury, narrow, and guarded by a strip of linen around its blade,
would answer the same end with less risk of producing fistula, and would
penetrate better ; but it is not as easily managed, nor so convenient for intro-
ducing a canula afterwards. The patient is made to assume the same atti-
tude as for lithotomy. He might, in strictness, lie with his abdomen on the edge
of a bed, with the legs pendant, unless such a posture added too much to
his sutferino-s. If so, the surgeon would need no assistants, and would be
more at ease for piercing perpendicularly the bas-fond of the bladder. In
either case the fore and middle fingers of the left hand, besmeared with cerate
or some fatty matter, are introduced into the rectum to reconnoitre the
vesical projection and the prostate gland ; stretch the parts by diverging from
each other a little, and then are held firmly at some distance from the gland,
the palmar aspect being turned forwards, their fleshy parts or the nails butting
on the distended cyst, to serve as gorget or director to the trocar. The latter
is carried in with the right hand, its concavity forwards, to the intestinal
surface of the trigoifal space, between the peritoneal cul-de-sac and the base
of the prostate ; it is then passed suddenly in, as if it were intended to be
carried towards the umbilicus, that is to say, forwards and upwards obliquely.
When its point has overcome the resistance and has entered the bladder, a
few drops of urine escape by its lateral gropve, which gives the assurance
that no error has been committed. The blade of the trocar is then with-
drawn. The urine flows, and as soon as the bladder is emptied the operation
is over, unless we adopt the plan of fixing a tube in the wound. In that case
a, very elastic and flexible catheter, wrapped round with lint that it may be
kept motionless upon the perineum, with the assistance of a T bandage and
some compresses, is preferable to the canula of the trocar, which however will
serve to direct its introduction. It is nevertheless doubtful, whether such a
tube be necessary at all. In Hamilton's patient the wound re-opened of itself.
Even if it did not, a second puncture would be attended probably with less
inconvenience than would result from the long continued presence of a
foreign body in the bladder and rectum. Finally, it would be useless at any
rate, to leave the canula in longer than is necessary for the cohesion of tissues,
that is to say, beyond four and twenty hours, for the inflammation which
surrounds the little wound, although it puts no serious obstacle in the way
of the issue of urine, still no longer allou^ of its infiltration into the meshes
of the recto-vesical septum.
110
874 KEW ELEMENTS OF
Jirt, 3. — Hypogastric Puncturing the Bladder.
The very opposite statements published in the last century by MM. Hoin
and Noel, on the subject of this operation, prove that puncture above the
pubis, which ought to have originated about the same time as hypogastric cutting
for stone, had at that time but very few advocates. Tolet, Drouin, Turbier,
Mery, Morand, and a small number of others, were, according to M. Belmas,
the only ones who had performed it. But the authority of Brother Come, of
Bonn, Paletta, and of Soemmering especially who became publicly one of
its most strenuous patrons, ultimately succeeded in bringing it into vogue in
Europe, in spite of the efforts of Murray and Mursinna to establish that
through the rectum. In France it is the only one which for a long time past
has been performed. The case of intestinal puncture which is contained in
the thesis of M. Duplat, and the two examples which have been contributed
by M. Cabanell from the practice of M. Magnan, are rare exceptions which
escape attention.
The straight trocar originally employed being liable to wound the organ
behind it, and the beak of the canula, if left to remain in, being capable of
ulcerating the posterior wall of the bladder, as it contracts upon itself after
the evacuation of its contents, the curved trocar of F. Come has been gene-
rally adopted, whether puncture is performed without previous incision, or
whether, after the method of Abernethy, the hypogastric paries is cut through
with a bistoury before the trocar is employed. However, the operation
is really so easy that the previous incision seems an unnecessary complication
of it. The patient is made to lie horizontally upon the right edge of his bed.
The surgeon feels for the upper edge of the pubis and the median line; applies
the point of his trocar at about an inch above the symphyses ; plunges it in at
a single blow, from above downwards, and from before backwards to the
bladder, which it reaches after a course which varies according to the embon-
point of the patient, and individual peculiarity of structure. The blade
of the trocar being withdrawn urine flows out, and the canula, which is closed
with a plug, is afterwards fastened around the body by means of strings which
are attached to the lateral parts of its handle. But the canula is by tkr more
dangerous above the pubis than in the rectum. When it is too long it causes
ulceration of the organ ; when too short its beak, separated from the bladder
by the retraction of that organ, enters the surrounding cellular tissue and
remains there. If it be not often changed it may become encrusted with
calculous conci-fetions and is not easy to remove. Having withdrawn it, it is
not always easy to replace it. The gumelastic catheter carried into the
reservoir of urine through the metallic canula, and which is left in instead of
the other, being of smaller diameter does not completely fill the wound, and
allows of urine flowing between the tissues and the foreign body. The
flexible sheath, acting as a chemise to the instrument which is made to penetrate
by M. Jules Cloquet, in such a way as that on withdrawing the trocar to let
the urine flow out, and then the canula afterwards, it is alone left within the
solution of continuity, is but an imperfect remedy for the inconvenience. It
must always be shorter than the metallic tube, upon the outer surface of
which its lower extremity always forms a projecting circle of more or less
OPERATIVE SURGERY. 875
irregularity, no matter what be done to thin and smooth it. Thence originates
a series of elevations, or knobs, which it is more difficult to act on through the
tissues. It would be erroneous again to suppose that a tube will long remain
in close contact with an incision, the outline of which is precisely the same
as its own circumference. Indeed this is no longer so after the lapse of a
few hours, and the fluids pass readily between the canula and the wound.
Of this, bougies and catheters in the urethra every day give proof, and I
saw it verified at the hospital St. Louis in 1822, in the patient whose case
gave rise to the above change in the instrument. All these reflections go
to favor the reasoning of those who advise that nothing be left in the wound ;
and who prefer, in case of necessity, to repuncture the bladder after it has a
second time become distended. I should entirely coincide in their opinion
were it not that the more speedy approximation of the puncture in the abdo-
minal parietes than that of the bladder, exposes to the risk of the filtration
of a few drops of urine into the pelvic cellular tissue, and if the inflammatory
state of the wound were not at the end of a few hours changed to one of a
fistulous character.
A patient upon whom I performed it twice in three days, died on the sixth
of peritonitis, which in him however, evidently existed before tha puncture.
A blackish abscess of limited extent was visible between the forepart of the
bladder and the bottom of the hypogastrium.
Art. 4. — Reciprocal advantages and inconveniences of the different species
of Puncture.
Each species of the vesical paracentesis has in its turn been lauded or
proscribed to the exclusion of either of the others, and according to custom
the strict truth has almost always been exceeded. Recto-vesical puncture,
thoujj-h not as terrible as Soemmerins; asserts, is far from beino; as safe as it is
pretended by Murray. Tumors in the neighborhood of the anus, the thickness
of the septum at the entrance to the intestine, may render it of painful and
doubtful, or of impossible execution. The instrument may escape into the
cellular tissue of the pelvis, between the bladder and rectum, and open the
peritoneum when this membrane descends considerably towards the prostate;
or, when tlie puncture is made a little too high up, it may wound the vasa
deferentia, the vesiculae seminal es, or even the ureters, if it be made laterally
or too low. The organ being wounded very near the urethra, and con-
sequently to the seat of disease, werunin this respect great risk of increasing
the danger. Lastly, the wound may remain fistulous, allow of the entrance
of stercoraceous moisture into the bladder, and give rise to symptoms which
may prove fatal. It is true that the greater part of these difficulties will be
most frequently overcome by a skillful operator, and that the unpleasant con-
sequences of which I have just spoken are not all unavoidable. Fistula,
however, the occurrence of which no skill or knowledge on the part 6f the
operator can prevent, as is proved by the observations related by Bonn, Paletta,
Angeli, and others, is of itself a very serious aff*ection, and its cure is too
difficult to permit us to incur the risk of inducing it whenever it is possible
to avoid it. In exchange for so many objections, puncture through the in-
testine has the advantage of being generally easy, of bearing upon the bladder
876 NEW ELEMENTS OF
at its most depending point, of passing through but a smali extent of tissues,
and those tissues of too dense a nature to create much dread of urinal infil-
tration or abscess, which have nevertheless been sometimes observed, particu-
larly in one patient mentioned by M. Nauche, of rendering the use of a canula
easy and of not confining the patient rigidly to his bed.
Super-pubic Puncture is unsuited to cases of retention caused by bruises,
inflammation, or tumors of the hypogastric region. It must needs give rise
more than any other to infiltration and to abscess. The bladder being opened
upon its anterior surface, is emptied with difficulty and does not bear the
presence of the canula as well. We are obliged sometimes to go to a great
depth to find the organ, and the peritoneum is not entirely sheltered from
danger. But there are no fistula to be feared, for even if the wound should
assume this character there would be no cause for anxiety. The peritoneum,
crowded over from the pubis by the sole effort of the distended bladder, it is
easy to avoid, and to miss piercing the bladder with the trocar is next to
impossible. The operation is still easier than that per rectum, and not more
painful than tapping the abdomen ; it acts upon a part of the organ which is
not altered in structure, irritable or irritated.
Puncturing through the perineum is, beyond comparison, more uncertain
than that through the hypogastrium ; and endangers the urethra, or vesicula
seminales, as does that through the rectum. It may be done too far forward,
between the pubis and bladder; or too far backward, and enter the peritoneal
cul-de-sac or the intestine; or it may enter the bladder by lacerating its
parietes. The vessels of the perineum and the prostate ghmd, are neither of
them secure from injury by the instrument. Abscess and infiltration are not
impossible, and the presence of a catheter is no where more annoying.
The sole advantages of this puncture are, that it opens the bladder in a
depending part, without exposing to fistula?, as that through the rectum; it
makes an easier exit for urine, and does away with much of the danger of
urinal inflammation, incurred by that above the hypo,2;astrium. Tiiough few,
these are important advantages, and but that they must be bought so dear, and
if they were real, perineal puncture would bear away the preference over the
other two. Now to me it seems that a mere slit in the urethra is better than
either of them, and enables us to avoid.neighboring organs with every certainty.
As it is no otherwise objectionable than that it is rather more delicate and
rather less speedy, I think it preferable every time that the shape or texture
of the perineum is not too much changed from a normal state, and where the
person who is to perform it has some experience in surgical operations.
In other cases super-pubic puncture should receive the preference, and
recto-vesical tapping be reserved for occasional exceptions, and for circum-
stances which prevent special obstacles to the passage of instruments through
the natural passage.
As to penetrating from before backwards through the symphysis, which
Mr. Brander advises, and states himself to have performed, it is a method
which will meet doubtless vvitli but few defenders ; first, because after matu-
rity it would be often next to impossible ; and, secondly, because it would be
no safer on the score of infiltration than hypogastric puncture. It would be
rash also to practice puncturing the bladder without some urgent indication;
as, for example, for a retention caused by a mere spasm of the urethra, of
OPERATIVE SURGERY. S77
%vhic]i M.Racine mentions two cases; for the supposed spasmodic contrac-
tion to which Mr. Holbrook has recently directed professional attention ; but
to M'-ait too long would also add to the danger. The bladder of a person who
has not made water for twenty-four, thirty-six, or forty-eight hours, being
distended to an excessive degree, may give way and even burst. Pain, fever,
and a partial entrance of the urine into the circulation, soon throw the patient
into so alarming a condition that puncture can no, longer avail in saving
his life, nor prevent a host of occurrences which a few days before might have
been avoided. The observation just cited, is my own, and furnishes new
proof.
SECTION V.
Urinary Fistulae.
Recto-vesical fistulae, which are no less dangerous and still more unyield-
ing than those in the vesico vaginal septum, are healed in the same manner by
similar procedures. The surgeon, however, always commences by restoring
the urethra to its natural dimensions, when it is strictured ; by depressing the
prostate gland with the assistance of the redressor, an instrument contrived
by MM.Tanchou, Pravaz, and Leroy, when its size is such as to impede the
iiow of urine; and by destroying all obstacles which the bladder may ex-
perience towards ridding itself by the natural passage. Desault cured recto-
vesical fistula following cutting for stone, by incising all the parts situated
between the wound in the perineum and that in the intestine, including the
sphincter ani, so as to lay the whole into one incision. But if the first incision
had long been healed, either this procedure would be applicable, or would
require some modification. We might in such a case advantageously imitate
the method of Sir Astley Cooper, who re-opened the prostatic portion of the
urethra upon a catheter, through the perineum, and. from before backwards,
so that the urine having issue anteriorly might allow of the closure of the
posterior orifice ; and entirely succeeded by it in one case. Ai» incision with a
bistoury, drawn out from the fistula to the perineum, upon the groove of a staft'
as in the recto-prostatic operation for stone, would be easier and surer than
Desault's oblique operation, if Sir A.Cooper's did not seem likely to suffice;
but it exposes the veru-montanum and ejaculatory canals to injury.
Fistulse which are of the kidneys, the ureters, the top or face of the
bladder, which do not open exteriorly, or are within the intestines beyond
the reach of instruments, can derive no succor from surgery, unless they de-
pend upon some impediment, such as a calculus or a stricture, for example,
which might either be removed or destroyed. Fistulae at the umbilicus, owing
to a continuance of the urachus, are of the same kind.
Spontaneous Cure. — In the urethra it is not always so. In the pars spon-
giosa they rarely fail to disappear spontaneously, after care has been taken to
restore the natural dimensions of the canal. Towards the fossa navicularis
at which M. Barthelemy has seen them open, like the top of a watering
pot, on the gland, they will be closed almost with certainty by confining the
patient to urinating for several days through a catheter, as was done by that
878 NEW ELEMENTS OF
surgeon ; and moreover, by taking care every time that the bladder is being
emptied, to place the finger firmly behind the glans so as to keep the canal _
closely applied against the instrument.
Injectiona. Cauterization. — Fistulas of the bulbous, membranous, and
prostatic portions, usually most frequent and most obstinate, are the only
ones which merit special attention. The first and only course to be
adopted, whether there be one or several external apertures ; whether they
be sinuous or straight; whether they go to terminate at a long distance
from their starting point towards the scrotum, in the groin, in the nates, in the
anus, on the inner part of the thigh, at the extremity of the labia majora in
the female ; whether they stop at the perineum ; is to sound the urethra and
destroy all its strictures. If they resist this preliminary treatment, recourse
must be had to irritating injections with alcohol, vinegar, the dilute mineral
acids, to caustic, the nitrate of silver, to troches of the deutoxide of lead, of
nitrate of mercury, to compression, and, in a word, to the different medica-
tions used in cases of fistula generally, and which properly appertain to the
science of chirurgical pathology. If they still remain incurable and sinuous,
they must be cut into, and their fundus laid bare ; after which derivative
catheterism, a re-application of caustic and suture, can alone effect their cure.
Some few, resisting every method, end in time by getting well of themselves.
Of this I have just seen a fresh and remarkable example in the^case of a dis-
tinguished physician who, having exhausted every means of treatment pointed
out to him by MM. Boyer, Dubois, Dupuytren, Richerand, Marjolin, Roux,
Cloquet, and myself, recovered in this way.
Derivative Catheterism succeeds only in those fistulas in which there is
either no loss of substance at all or very little, whether preceded by stricture
of the urethra or not. Neither the permanent gumelastic catheter, the S
shaped catheter which J. L. Petit employed, that with a fixed curve such as
Mr. Hey recommended, the strongly-curved instrument advised by Dr. Phy-
sick when there exists engorgement of the prostate, nor the flexible one which
maybe directed at pleasure, which since Desault has been generally employed
in France, are always without their inconveniences. If they remain open so
that the urin%may run off as fast as it is deposited from the ureters in the
bladder, the point resting against the posterior paries of the organ irritates
and ulcerates it, even perforating it sometimes. If they are kept closed the
small quantity of urine which almost always passes them and the walls of the
urethra, suffices, in most cases, to prevent the obliteration of the fistula. This
fact was well established by M. Asselin in his thesis in the year 1803. It is
better, therefore, to pass the catheter every time the patient desires to
urinate, or better still, let him learn to pass it himself, giving the prefer-
ence to a silver instrument. A patient whom, without success, I treated
with catheters permitted to remain, in 1830, at La Pitie, recovered entirely
in three days after I began to have tliem passed every four or six hours, and
afterwards withdrawn. Caustic may be combined with catheterism ; and
indeed, where the cure is protracted for a week or two, becomes indispen-
sable. If the disease continues after a lapse of six weeks or two months, we
may, without incurring censure for our precipitation, resort to the last chances
left.
Suture is performed upon this as upon every other part of the body. We
OPERATIVE SURGERY. 879
begin by making a slit of the fistula of an elongated form, more towards tlie
integuments however than towards the wall of the urethra. Having stimu-
lated the edges and removed their callous portions, and having brought them
together over a flexible catheter, destined to remain permanent, they are
maintained in the most perfect apposition possible, by means of a suflicient num-
ber of small points of the twisted suture ; the points should not be more than
three or four lines apart, if we do not wish to see the urine oozing through
them, and should for the same reason be so tight as to effect immediate adhe-
sion. We then apply over the perineal fissure, some lint and compresses,
and support the whole by moderate pressure. If all does well, we take out
the pins on the fourth or fifth day, beginning with those at the angles of the
wound. The catheter is left in a day or two longer. This is in turn
removed, and the patient is cured. M. Cloquet has recently been success-
ful in a procedure of this kind. Unfortunately, as the fruitless attempts of
Mr. Charles Bell too clearly demonstrate, one is not always so fortunate. It
becomes frequently necessary to repeat the operation often ; nor even then
is it rare to see all the skill of the surgeon and the patience of the patient
terminate in an increase of the size of the fistula.
Urethraplastic Method. — When the loss of substance is at all extensive,
simple suture is seldom indeed sufficient. The modification invented by M.
Dieft'enbach, which is as applicable in other cases as in this, may be of essen-
tial service. Proceeding on the Celsian precepts for the hare-lip operation,
this surgeon makes an incision longer or shorter on either side, an inch
or half inch beyond the ulcer, which should extend as far as the apone-
urosis. Then having performed suture in the usual way, the result is
great relaxation of the old sore, the agglutination of which there is now
nothing to impede. When this is aff*ected, the lateral incisions heal like any
other simple wound. In this way M. Dieffenbach has at the Charitc of
Berlin, cured fistulae over which no other treatment could triumph, and I
think his conduct well deserving of imitation. But it would be wrong in
any one so much to exaggerate its value as to regard it as of never failing
success. The very great distinction of tissues, such as we see consequent
upon gangrene of the scrotum, perineum, certain operations, &.c. will continue
to require something more than this. The only chance of recovery then
offered is from the recto plastic "method. It was tried in London once by
Sir A. Cooper and succeeded ; by him again another time and it failed. Mr.
Earle performed it twice upon the same individual, who ultimately got well.
In France, I believe the only person who has attempted it is M. Delpech ; yet
in spite of his acknowledged skill as an operator, and although the operation
was frequently repeated in the same individual at different times, the
fistula continued open. Instead of taking a portion of integument from
towards the scrotum, or from the sides of the penis, as has been done by
English surgeons ; or borrowing it from the groin or inner surface of the
thigh, as the professor at Montpelier preferred to do, which he might turn
over and fasten to the re-animated edges of the fistula by means of simple
suture ; it would be perhaps better to follow the advice of M. Roux, for the
cheiloplastic of M. Dieffenbach, for the rhinoplastic methods ; to act, in a
word, by dissection and re -approximation, rather than by turning over of
points. If so, the fistula being arranged as if it were intended to perform
880 NEW ELEMENTS OF
common suture, its two edges are to be dissected alternately from withir
outwardly, to an inch more or less towards the root of the thighs in such a
way as to form flaps, which are to be made as thick as possible. The edges
are then to be stimulated either by the use of a bistoury, or of good scissors:
and are then coaptated either with simple or twisted suture. Graduated com-
pression exercised laterally upon them, will keep them closely applied against
the subjacent tissues, and will guard against the infiltration of urine. Expe-
rience, however, has not yet decided in favor of this method of operation, and
consequently I shall not go more largely into its detail. I must say the same
of the procedure of which I spoke when upon the bronchoplastic method,
and afterwards of hernia ; because, having not yet practised it in a case of
urinary fistula, I can only look upon it as one very likely to succeed.
Congenital Urethral Fistulse, near to the glans, admit of no other operation
than the creation of a new canal in the thickness of the penis, which was once
performed by M. Rublach, and with success.
CHAPTER VI.
THE ORGAN OF DEFECATION.
SECTION I.
Defects of Structure.
Art. 1. — Imperforation,
It is common in nevy'ly born children to see the rectam open into the
bladder or vagina, into the perineal portion of the urethra, or towards the
posterior part of the vulva, instead of ending at its proper aperture, the anus
in front of thp coccyx. Still more frequently it ends in a cul-de-sac, above
its natural termination, more or less high, up in the pelvis. The first cases
belong to the category of unnatural anus, and are coeteris paribus, less inevi-
tably fatal than the second. The meconium infused into the bladder is
softened there and diluted, and may pass from it for some days. A child
vv^hom I saw that passed it per urethram, lived nearly a week. The orifice
of the receptacle, and the size of its excretory duct, are so small however
that when the fecal matter acquires mucii consistency, life cannot be
supported, because the urinary organs cannot long endure without danger
the immediate contact of stercoraceous substances. Recto -vaginal anus,
recto-vulvar anus, and indeed all external anuses resulting from defects of
conformation, are disgusting infirmities, but do not necessarily cause death.
But, on the contrary, where the intestine is devoid of opening entirely, or
opens into an organ which has no outlet externally, the child sinks rapidly.
In either case art has but two resources to oppose ; 1st, to re-establish the
anus in its natural situation ; 2d, to create one artificially in some part of
i}iiQ abdominal cavity.
OPERATIVE SURGERY. 881
§ 1. Re- establishment of the Natural Anus.
To re-establish an anus which is closed only bj the integuments, or by a
layer of tissue not more than a few lines thick, is not an operation of any
difficulty. A projection or a bluish spot usually point out its situation, and
the obscure fluctuation which is at times perceived by the fore-finger, allows
of our proceeding fearlessly. Instead of surrounding it by a circular
incision, as Levret advises, the surgeon passes the point of a straight bistoury
or a trocar, in at the middle of the spot, in the direction of the rectum, until
he comes to the meconium ; then enlarges the puncture in its antero-posterior
direction, and transversely cuts away the four flaps thus made ; places in the
opening a pledget or tent of lint, or ^ suppository of some sort, to prevent it
from closing ; and continues dressing it with dilating substances until it has
entirely healed. Many successful results have been obtained in this way,
and in like cases no one should hesitate to adopt it. The same operation
would be required if, the anus existing, the rectum were closed by a septum
some way up. Only it might then be proper to surround the bistoury with a
stripof linen, unless we preferred J. L. Petit's trocar or M. Martin's pharyn-
gotome. In these cases it is not practicable to excise the angles of the
conical incision.
It would be easy to re-establish an anus opening at the fourchette, a case of
which in a little girl M. Brachet has just published. All the tissues which
have kept up the deviation from the natural course may be divided by a
straight bistoury passed into the intestine through the fistula upon a director,
and withdrawn from before backwards, or from the perineum towards the
coccyx, and from above downwards. A canula fastened in the rectum and
carried up as far as into the posterior angle of the wound, will allow the
solution of continuity to heal in front, and enable the fecal matters to re-
sume their normal direction. Vicq d'Azyr has recommended the same
operation for vaginal anus; and the advice of Mr. Martin is to divide, first,
the whole septum from above downwards, and from before backwards, as
previously mentioned ; then to place the canula in such a way as that supe-
riorly it shall go a little beyond the fistula; and afterwards to re-unite the
wound by means of stitches on its anterior surface. This last step in the
operation, by far the most difficult, does not seem to me to be necessary. If
the tube which is to carry off the fecal matters from the fistulous orifice, be
suitably placed, the divided tissues will unite very well without (he interven-
tion of stitches.
There exists, moreover, another mode of avoiding this, and arriving at the
same result with a less inconvenience, viz. to ascertain, by means of a blunt
instrument curved like a crotchet, introduced into the fistula from above
downwards, how low the intestinal sac descends, and to enter the rectum by
puncturing from the skin towards the pelvis without any division of the recto-
vaginal septum.
In children of the male sex we have not the same resource. The exit of
meconium only at the moment of the flow of urine, though a proof of the ex-
istence of an entero-vesical anus, neither points out the precise '&^At or
direction of the end of the rectum. If it escape incessantly, or at intervals,
111
8B2 NEW ELEMENTS OF
without any ad mixture of urine, it may be presumed that the aperture is in the
urethra ; and although it may not always be discoverable whether it be a short
way from the glans, as seen by M. Cruveilhier, or more deep towards the
perineum as is oftenest the case, we have yet some right to expect success
from methodically puncturing where the rectum ought to be. In the first
case, and in those likewise in which externally nothing exists to lead to any
suspicion of the state of parts within, the operation being undertaken in a
measure at random, naturally offers a less chance of success. It would be a
remedy at least as disgusting, if not as dangerous, as the disease itself, to cut
into the perineum and neck of the bladder as in operating for stone, for the
purpose of making a large aperture common both to feces and urine, in cases
where the intestine had its outlet with that of the bladder.
The child upon which M. Cavenne of Laon, thought proper to perform it,
died the same evening; and M. Martin of Lyons, who proposed it, never
probably reflected that as the operation left the recto-vesical anus in its state
of original contraction, it would not even be advantageous in prolonging the
life of the new born infant.
The only method which has thus far been attended with any success, is to
go in search of the intestine through the tissues by wliich it is separated from
the skin. The child is to be held upon the knees of an assistant, or on a
covered table, with its limbs separated and bent. The surgeon facing it
examines the groove between the nates, or the interperineal fissure, if it exists ;
and if he discerns no trace of intestine or anus, endeavors to detect the point
of the coccyx ; places the centre of this cut about ten lines forward of that
bone ; first, divides the skin to an extent of from ten to twelve lines, and then
successively the tissues beneath to a depth of one or two inches, that is, until
he comes to the intestinal cul-de-sac, if any, or until he abandons all hope of
finding one. The left fore-finger, which acts all the time as a guide to the
paint of the bistoury, passed down to the bottom of the wound, occasionally
for some moments together wiU not fail to percieve the projection and
fluctuation in the distended 'organ, and will serve to show the direction in
which the point of the bistoury or trocar should be passed. This dissection
will at first be made in the axis of the body, i. e. perpendicularly nearly, but
it must afterwards incline towards the sacrum by degrees, to follow the
natural course of the rectum, and to avoid wounding the bladder. In this
respect a trocar is a less certain and safe instrument tlian a bistoury, for as it
enters blindly, it would inevitably pierce the bladder, which fills nearly the
whole pelvis, if there should prove to be no intestine. Besides which it gets
too easily lost among the soft parts to be here deserving of much confidence.
Puncture of any kind could supersede dissection without disadvantage, only
when the cul-de-sac, filled with fecal matter, is perceptible either by tlie fin-
ger or to the eye ; either on the skin or at the bottom of the wound. Having
once entered the gut, it is skillfully to be enlarged in various directions, and
in that particularly in wlftch there seems to be most space. A tent of lint
or linen is then passed in, or else a canula, and the operation is at an end.
We have then only to keep open the new anus to give it size enough, and
prevent its contraction or obliteration. This operation, for the performance
of which opportunities often occur, is rarely followed by complete success.
Uoonhuysen, F. Hildanus, de la Motte, &c. who have had most reason for
OPERATIVE SURGERY. 883
praising it, admit that their patients ultimatelj perished at the end of a few-
months, or one or two years ; and B. Bell, in whose hands it had some suc-
cess, states positively that it is almost impossible to prevent the new orifice
from closing. The cure obtained by Wagler, which continued unimpeded
in a patient whose perineum he uselessly incised, and on the following day
thinking he could feel the rectum at the bottom of the wound, passed a lancet
into it, was owing doubtless to the intestine being near the sphincter, and to
his not being obliged to go deep. I must say the same also of the case of a
little girl, upon whom a surgeon operated, who is mentioned by M. C. L.
Lepine, who died three years afterwards of a totally different disease ; and
of a more fortunate one still, reported by Mr. Miller.
The reason for the want of success, is but too easy to give. The absent
portion of intestine can never, otherwise than very imperfectly, be restored.
It is placing of a fistula in lieu of a natural tube. The species of mucous sur-
face, which is at length formed, represents the tunics of the natural organ but
very imperfectly. Though the organism may fail to close a stercoral fistula
entirely, it nevertheless is constantly striving to diminish their size ; so that
they soon become mere passages for the escape of fluid substances.
The absence of sphincter is another hopeless cause of its failure, especial-
ly. When this is the case it becomes extremely improbable that the opening
artificially made can be l^ept up with any ease. Still it is not to be sup-
posed, with Dumas and some others, that in every case an artificial anus in the
side of the abdomen is preferable. This is no other than a fistula Avithout a
sphincter, and whenever it can be made in the perineum, will be attended
with fewer disagreable occurrences to the patient.
§ 2. Tlie Estahllshment of an Artificial Anus.
The first person who, in a case of imperforate rectum, conceived the idea
of making an artificial anus in the iliac region, in the sigmoid flexure of the
colon, was Littre, in 1720. It is scarcely conceivable how Dumas, who re-
peated the proposal in 1797, should have given himself out as its inventor.
M. Dubois had performed it before him, in 1783, upon a child who died on the
tenth day. On the 18th October, 1793, M. Duret of Brest, performed it with
complete success ; and Pilore in Rouen, was not less fortunate. But the
child upon whom Desault operated in 1794, lived only four days afterwards.
The abnormal super-pubic anus, noticed by Voisin of Versailles, comes in aid
of the hopes raised by the results obtained by Duret and Pilore, as the child
lived and discharged its feces by this passage. It is true that they have since
then been in several instances disappointed. M. Ouvrard of Angers, lost his
patient as quickly as Desault in 1820 ; and M. Roux was as unsuccessful last
year in a similar case. Where, after all, is that operation which does not
sometimes baffle tlie attempts of the surgeon .''
The little patient lies upon its back, its thighs extended, and is held by one
or two assistants. The surgeon, conveniently seated, makes an incision of
about two inches long, a little above the Fallopian ligament, between the
anterior superior spine of the ilium and the pubis,; divides, layer by layer,
skin,/asaa superficialis, the aponeurosis of the obliquus externus muscle, the
lower fibres of the small oblique, the fascia transversaliSytind peritoneum, the
884 NEW ELEMENTS OF
aperture in which he subsequently enlarges by employing a grooved director
as a guide to the instrument. The distended intestine, of a livid or greenish
hue, shows itself behind the wound, and may be known moreover by the
appearance of its covering, and the disposition of its fibres. The fore-finger
seeks for it and brings it outwardly by acting as a hook, or else by assisting
the thumb to lay hold of it. A loop of thread is then passed through its
mesentery by which it is prevented from returning. It is opened in the direc-
tion of the wound in the belly. Feces escape ; it becomes empty. A tent or
pledget is then placed in it, if there is any fear of its closing too soon. Ad-
hesions are soon formed between the surface of the colon and the walls of the
wound in the abdomen. The loop of thread is withdrawn from the mesentery
on the third or fifth day, and tlie new anus, then definitely established, requires
no other care than any new formed anus whatever.
2. Procedure of Callisen. — This consists in piercing the side to get at the
left lumbar colon between the two portions of its mesenteric fold, without
opening the peritoneum, but has never been performed upon the living sub-
ject. I am wrong. M. Roux once applied it to a little patient who died in
two hours afterwards. It does not deserve to be rescued from the oblivion
into which modern surgeons have thrown it. It would be incomparably more
difficult, and not less dangerous than the preceding, as well as being much
more inconvenient.
3. Procedure of M. Martin. — The project attributed by M. Paris to M.
Dubois, and which served as the text of M. L. A. Martin in his thesis, of car-
rying in at the iliac opening of the intestine made according to the procedure
of Littre, an exploring instrument from above downwards for the purpose of
seeing whether it might not be possible to re-establish the natural anus by
perforating the perineum, has also hitherto been attempted only on the dead
body. It would be unjust, however, entirely to despise or reject it. If a
mistake should by chance have been made, and the rectum should have
descended low enough to be continued as far as the skin without too much
difficulty, we should be still better enabled to perform the operation. A
flexible catheter, or one conveniently curved, would first point out the state
of things. I would not, however, advise either the large flexible canula, nor
the enormous trocar recommended byM. Martin, to transfix the parts from
within towards the exterior. It would, in my opinion, be better to penetrate
through the perineum in search of the beak of the catheter; or if it were
found practicable to pass into the pelvis the sonde-a-dard, the dart and stylet
of which pushed towards the surface in the direction of the anus, might serve
as the guide to the bistoury during the rest of the operation. But as it might
be somewhat imprudent thus to multiply incisions at one time, and as there
would always be time enough afterwards to emplpy this resource, it might be
as well to wait until the health of the child is restored to its natural state, and
to choose some apparently more convenient time for its performance.
If experience had sufficiently demonstrated the innocence of Littre's me-
thod, its advantages would not be confined altogether to new-born children.
It might be likewise applied to remedy the many cases of intestinal oblitera-
tion which show themselves after birth. As every stricture of this kind is of
a fatal nature, we can see no reason why an artificial anus should not be
established. The difficulty would evidently be to acquire the certainty that
OPERATIVE SURGERY. 88^
there exists any obliteration at all, and next, to be sure that it is situated in
the rectum or lower portion of the sigmoid flexure of the colon, or in the
large intestine at least, so that by making the anus in the right fossa iliaca it
might be above the disease. This, however, may often be arrived at.
Brail! et entertained no doubt of it, in the patient whose case he has commu-
nicated, nor was M. Martin Solon deceived in the fact quoted hy M. Paris.
The circumstance was equally clear during the illness of Talma. I might
say the same of the case of a woman whom I examined after death at the
Clinique Externe in 1825.
The procedure, moreover, would require no other alteration save that, in-
stead of being always carried to the left, it might become indispensably
necessary to direct the action of the instrument upon the right fossa iliaca, if
the transverse or ascending colon were attacked by the stricture. After all,
how^ever, the operation exists not in theory only. Surgeons have been bold
enough to perform it upon the living human subject, and M. Martland, who
first attempted it 1814, was fortunate enough to cure his patient.
*^rt. 2. — Strictures,
Strictures, whether congenital or artificial, v^hich are not cancerous, but
merely organic contractions of the organ of defecation, may be overcome by
operations similar to those performed upon the urethra. Their great fre-
quency at the upper part of the anus, is explicable by the species of fold or
valvular border seen within the rectum a little above the sphincter, which
represents a species of pylorus, and upon which, before Mr. Houston of Dub-
lin, no one had ever laid any stress. Higher up than this, they are almost
always consequent on ulceration, and upon degeneration of a kind difiicult
to be restrained, and therefore they yield less frequently than the former to
surgical remedies.
§ 1. Dilation.
The use of dilation in stricture of the lower portion of the rectum, so
highly lauded by Desault, and since him by a majority of surgeons, do^s in-
deed deserve a good deal of the praise which it has received.
All those indurations, results of chronic inflammation, which involve the
mucous membrane only or the subjacent cellular tissue, and even some larda -
ceous degenerations, admit of the application of this means of cure. Dilation
here acts by the same meclianism as does compression in external congestion.
The excentric pressure which it causes, forces the effused solidified sub-
stances in the natural organic meshes of the tissues to re-enter the general
circulation, thus bringing back the intestine by degrees to its original thick-
ness and increasing its size ; and by extinguishing its principle, often remov-
ing the morbific process. This result is not, however, attained with equal
facility on all parts of the rectum, nor in all species of stricture. Dilation, in
all cases where the disease consists of irregular tumors extending more out-
wardly than within the canal, in which it occupies a point too badly
surrounded to allow of accurate pressure, or if the apparatus is ill applied,
generally does more harm than good. It is performed with rolls or tents of
886 NEW ELEMENTS OF
lint, spread with cerate or some medicated pomatum, renewed every day, and
gradually increased in size.
These tents, for which, in fact, any other supple or flexible cylindrical body
may be substituted, do very well for affections of the rectum high up, and
for those of the anus, properly speaking. But for such as are between the
sphincter and concavity of the sacrum, another course must be adopted.
A little linen bag introduced empty, like a purse with its bottom upwards,
filled with lint, so as to effect pressure from above downwards, as well as all
around, when an attempt is made to withdraw it, seems then to be better indi-
cated, and should have a preference over bladders distended with air, water,
or any other fluid. These two methods possess, however, the common incon-
venience of arresting the progress of fecal matters, and thereby in many
patients give rise to much uneasiness. It would, therefore, be well to follow
the advice of M. Bermond of Bordeaux, and employ his apparatus instead of
the tents or purse I have mentioned. This apparatus consists of two concen-
tric canulse, about six inches long, the inner one smooth, and endin<»; superiorly
in a cul-de-sac, the outer one open at both ends, and having circular grooves
at intervals on its exterior surface to admit of the adaptation of chemise. They
are sheathed in each other, and so carried up into the organ. Lint is then
passed up by means of a long forceps between them and their linen envelope,-
so as to press this out into an annular projection on a level with the top of the
instrument, and so as to bear more in this and less in the other direction as
may be requisite. The whole is fastened outside very firmly. When it
becomes necessary for the patient to discharge the contents of the bowels, the
inner tube is withdrawn without interfering with the other, which may have a
diameter of six lines. The lamp-bottom formed by the chemise above,
necessarily causes the fecal matters to accumulate there, which, if required,
may be dilated and made fluid by glysters. The central canula is afterwards
replaced, which catches, by a spur on its side, in a groove which exists in the;
enclosing canula near its free end.
When the disease is not within reach of the finger, neither the tents, the
linen bag, bladders, or the double canula of M. Bermond, are applicable any
loriger. For these particular cases, M. Castallat has contrived a little ap-
paratus which may be pushed up a distance of more than a foot, and which in
other cases also would not deserve to be slighted. I have already spoken of
it when upon the subject of strictures of the urethra. It also consists of a che-
mise, shaped like a condom^ preceded by a long, probe-pointed, or buttoned
stylet; it is carried up by a gumelastic catheter, and made into a tent by
means of cotton passed up within it by a forked stylet. The author assures
me that he has used it with great advantage upon a patient whom several dis-
tinguished surgeons had pronounced to be incurable.* It is to be regretted
that it is too complicated to become general, for the idea is an ingenious one ;
and it is very desirable to have it so much simplified, that every one should
be able to use it.
* The patient has since called at La Pitie, where I had an opportunity of examining him.
The stricture in the intestine has relapsed into its orig-inal state of contraction.
OPERATIVE SURGERY. 887
§ 2. Incision,
Before dilation was proposed, and even since it has been in general use, in-
cision into strictures of the rectum was practised, either as a principal remedy
or as an accessory means. Wiseman recurred to it three times on the same
individual, Foi-d had the good fortune to see his get well without a relapse,
and Mr. Copland states himself to have been as successful. The ope-
ration, unless it be necessary to go to a considerable depth, oiFers but few diffi-
culties.
The probe-pointed bistoury, carried flatwise on the forefinger, and intro-
duced within the constricted circle, is the only instrument we want. Its edge
turned towards the parietes of the intestine, divides the stricture in one or
several places, taking care not to pass the thickness of the viscus. A large
tent is then introduced to just above the wound, and the case is treated as a
simple dilation. The kiotome, or the instrument invented by Desault for cut-
ting frena, here finds an application, if any particular instrument is thought
necessary ; or the pharyngotome may be used, as was once successfully done by
M. Duplat. The incision becomes too dangerous when the finger can no longer
accompany the knife, for us ever to think of venturing upon it. Annular stric-
tures of a semilunar shape, or like a frenum, alone authorize its being prac-
tised ; and it can only be seriously advised as preparatory to, and as a means of
assisting, the operation of dilating instruments.
§ 3. Cauterization.
It is rather surprising that strictures of the rectum should not have been
treated with caustic as well as those of the urethra. Every thing leads
to the belief that it would have a like eftect; that the nitras argenti em-
ployed as a topical, or catheteric application, would very much assist the suc-
cess of dilation, by destroying the principle of chronic phlogosis upon the mu-
cous membrane of the intestine, as it so often has done in the excretory canal
of the urine. But I do not know that it has yet been used in such a case, and
having no data but theory and analogy, I cannot devote to it any long detail.
I find, however, a very conclusive instance of it in a thesis sustained in 1 823,
at Strasbourg, by M. Duplat.
SECTION II.
Acquired Lesions
^rl, ] . — Foreign bodies in the Jinus,
So various are the shades of difference in the shape, size, and nature of the
foreign bodies which become stopped in, or are introduced into the lower part
of the rectum, that no settled operation, nor fixed rule of procedure can be
laid down for extracting them, which has, so to speak, to be changed for each
particular case. The fingers and thumb, dressing or lithotomy forceps or
888 New elestents op
the whole hand when it can be introduced, are the means which first suggest
themselves. The hand of an intelligent child, as was used in the case of a
patient mentioned bj Nollet, who had pushed a phial of eau de cologne above
the sphincter, or that of a midwife should be used, if the hand of the surgeon
is too large. If the substance is wood, or vegetable, or animal matter, solid
and not flexible, a gimblet or a screw-ring [tire-fond), will be found of impor-
tant assistance, as the facts related bj Saucerotte and M. Bruchman prove.
A pig's tale introduced bj its base, the hairs of which previously cut, butt and
rise against the intestine at every attempt to withdraw it by traction, should
be managed in the way that Marchettis treated the prostitute who was made
the victim of their malice by the students at Gottingen. By means of a string
tied to its lower end, he succeeded in slipping over the foreign body a reed ca-
nala from below upwards, which separating it from the sides of the intestine,
and. acting as a sheath for it, enabled him to withdraw it directly without any
difficulty.
A patient once passed a sweetmeat pot into his rectum, its small end going
first. Violent irritation succeeded to this extraordinary proceeding, and the
intestine very soon turned over from above downwards into the vase, like a
red tumor filling up its cavity. Desault could only succeed in removing it by
applying two very strong forceps to opposite points in one of its diameters,'
one after the other. Instead of two, four might be employed if it were neces-
sary to pull still more strongly, or to separate the circumference of the anus
in more places at once. A large ring, a ferule, or a metallic goblet, would
not probably resist such treatment. If it were of glass, of crystal or porce-
lain, or any brittle substance, it might be broken with forceps, if it could not
be brought avv^ay in one piece. A narrow saw guarded by a gorget, and the
forefinger ought to be tried in case apiece of wood, horn, or ivory, should have
become fastened crosswise between the two walls of the gut; whilst a body of
steel, iron, silver, &c., will sometimes call for the use of cutting nippers, or of^
true shears. Biliary calculi, and that species of aegagropili which is met with
in the intestines of man, as well as in animal, require to be crushed by strong
forceps, or broken into fragments by long and powerful scissors, if they can-
not be overpowered by the hand, hooks, the screw or gimblet.
Hardened feces, concrete balls, and stercoral calculi, which in many
persons become sources of symptoms, the nature of which is never suspected,
often require the use of blunt hooks or the finger, of wooden spoons of greater-
or less length, or the delicate hand of a child or woman.
Divisions and incisions either of the anus, or intestine, on elevated portions
of its parietes, are never to be had recourse to, until the inutility or insuffi-
ciency of such measures has been fully established. Then, as in the preceding
cases, we are to employ the speculum brise, or else the simple speculum, made
incomplete by a slit of two or three lines in width, which divides it in its whole
length on its fuee side, as advised by M. Barthelemey, either as a means of
dilating the anus, or to assist the action of other instruments. The incisions
tliemselves are sometimes made with a straight bistoury wrapped round with
a strip of linen, sometimes with a probe-pointed, straight or crooked bistoury
guided on the finger, and thirdly, with good scissors.
Upon the whole, foreign bodies in the rectum, are treated in no way dilffer-
ently from those lodged in the vagina. To the means above specified, we may
OPERATIVE SURGERY. 889
add, I think, as appropriate in either situation, lithotritic instruments ; and it
may be borne in mind that the litholabe, the perforator, and the stone-breaker,
are much less dangerous to manage in the rectum, or vagina, than in the blad-
der and urethra.
Art. 2d,— Polypi.
Polypi of the rectum, though not very uncommon, are still not seen very
frequently. If they exist at a distance of six or eight inches up, it is next to
an impossibility either to reach or detect them. If seated lower they are easier
to get at, and require to be treated much as those which are situated in the
sexual organs of the female. It is too easy to excise them to render it necessary
to advise tearing them away, or the use of caustic, while ligature is in scarcely
any case applicable to them. When above the sphincter, they are to be hooked
with crotchet forceps, or a double hook, held by an assistant. If the anus
offers any resistance, a speculum brise must be introduced into it. The sur-
geon then, with a pair of long scissors, rather curved on their flat surface,
protected by the left foreftnger cuts off their peduncle. If still lower, the
method of excising them, is the same as that of haemorrhoids, which we shall
presently describe ; and in either case the measures hereafter to be mentioned
for guarding against hoemorrhage are to be pursued.
t^rt. Sd. — Hemorrhoidal Tumors.
Haemorrhoidal tumors, cushions, or tubercles, which are sometimes concealed
within the anus, and only visible when the patient strains on going to stool —
sometimes salient externally — are, when they continue in spite of the me-
thodical use of pressure, and the employment of antiphlogistic, detergent,
astringent, and catheteric topical applications, sources of many dangers
and inconveniences. Nitrate of silver would triumph over them in the begin-
ning only, or when they were yet of small size. The red hot iron, so much
extolled by the ancients, which M. A. Severin was so much displeased at
not being allowed to apply to a patient of high rank, because of that persons
cowardly physician's obstinacy, w^ould answer doubtless oftener and better ;
but the means possessed by art, of a surer and less alarming nature, have long
ago caused it to be forgotten. At the present day, in spite of the arguments
urged by M. Mayor in its favor, ligature, even though easy, is generally
abandoned. Tumors, such as the mere cushions, which have no peduncle,
do not allow of it use; and the cases mentioned by J. L. Petit,. show that
under other circumstances it may give rise to very serious symptoms, such as
violent pain, syncope, convulsions, inflammation of the intestine and perito-
neum ; and this, too, whether the morbid growth was allowed to fall off spon-
taneously, or whether, as Galen had advised, it was excised directly this side
of the ligature.
The only operation, then, to which they should be subjected is excision.
This of itself seldom ofters any great difficulty. The only alarming thing
about it is the bleeding which may follow ; and that process is consequently
the best which least exposes to the occurrence of this accident, and most
safely opposes it.
112
890 NEW ELEMENTS OF
The patient lying on the edge of a bed or covered table, one thigh (the
under one) being stretched out, the other flexed, so that the anus may be per-
fectly free, is to be held by several assistants. The surgeon facing the affected
part, is, according to M. Boyer, successively to take hold of every tumor, be-
ginning at the lowermost ones, and proceeding to those which are highest, with
good dissecting forceps or a hook, and to detach them one after another with
a bistoury or a pair of strong scissors. If they do not project outwardly, an
effort like that on going to stool will make them protrude ; but it is important, as
the pain of the removal of the first always occasions considerable retraction of
tlie anus by which the others recede into the rectum, to fix them all with as
many hooks or forceps, or by a thread before cutting any of them. It is wholly
superfluous to follow the advice of some authors, and dissect them out like
cysts, so as to remove as little as possible of the mucous membrane or skin.
It is much easier, besides, to give such advice than to follow it. Loss of sub-
stance can here be no source of disquietude ; the wound heals well, and after
the cure the organ regains its original flexibility. All the dressing required
Is merely the introduction of a large strong tent, spread with cerate, carried
in for a depth of some inches, supported outwardly by lint, compresses, and a
T bandage.
If less of blood is to be feared, the dressing is not quite so simple. M.
Boyer begins it by introducing very deeply a long tampon of lint, almost
cylindrical, hard, embraced by two strong ligatures, crossed on its upper end,
knotted, and firmly fixed upon its lower extremity, and the ends of which
gathered two by two, remain hanging out of the anus ; then he pushes in
several balls or fresh loose tampons below this; keeps them firmly in with a
strong roll of lint placed between the buttocks over the anal opening ; draws
on the ends of the two ligatures ; knots them over the roll of lint sufficiently
tight to draw down the lint contained in the intestine between the bleeding
surfaces, whilst the outer tampon tends to crowd it back from below upwards.
After this a soft mass of lint, a compress and T bandage, complete the whole
apparatus. In this way, it is nearly impossible for the blood to escape,
whereas mere tamponing would serve only to make it pour into the intestine,
since it could not show itself outwardly, making an invv^ard of an outward
hemorrhage, which would be more dangerous still. But, on the other hand,
if the pressure is not even, nor powerful enough, if the apparatus of Boyer
or J. L. Petit is not in good order, or illy applied, the same accident may
occur. Besides which, it sometimes causes great suffering, an insurmount-
able desire to go to stool, a weight which cannot be endured, colic, fever, and
other symptoms which render its use very distressing. It is indispensable,
therefore, in many cases, to have an assistant to hold it up for many hours
with his hand, to exhort the patient to make no effort, to resist with all his
moral firmness the desire to push which he feels, which seldom fail to diminish
in violence after a few hours.
I need scarcely add, that if the belly swells, paleness and syncope occurs,
with smallness of the pulse, indicating a continuance of the flow of blood ;
the whole dressings must be removed, in order that they may be better re-ap-
plied ; nor that the sensation of weight, and of the presence of a foreign body,
which are felt so acutely, even though no dressing be applied, will be
increased ioSvead of bettered by attempts at defecation to which the patient
OPERATIVE SURGERY. 891
is urged in spite of himself almost, but from which, at any sacrifice, he must
refrain. I would willingly advise the canula and chemise devised by M.
Bermond, if it had ever been tried under such circumstances. (See Dilation
of the Anus.) With it, pressure might be increased and diminished, and the
dressings changed, modified, and renewed, without undoing the whole appa-
ratus ; whilst the removal of the inner canula would allow us to ascertain
whether there was any eSusion of blood into the intestine, and permit the
feces to escape as often as is required, and this for days together if neces-
sary.
The procedure of M.Dupuytren does away with all such precautions. This
surgeon almost exclusively employs scissors which are curved on their flat
surface for the removal of hemorrhoidal excrescences ; and whenever he sees
reason to be alarmed about hemorrhage, directly applies the red hot iron upon
the wounds which he has made. He then places a very small pledget in the
anus, which is supported and protected as I have before mentioned. By this
procedure, accidents scarcely ever happen. Neither intestine, bladder,
nor circumjacent parts are distended, pulled upon, or irritated by any
thing. The congestion, which by the ordinary dressing is made so exces-
sive, is by this means rendered very inconsiderable, and hemorrhage, con-
sequently, has no exciting cause. In this respect, the red hot iron has
the effect of making the operation extremely speedy, and is not productive after
all of more pain than the use of tampons. The inflammation which has muc
less disposition to extend, and to be perceived at a distance from its seat,
does not attack the veins which open on the fundus of the wound, and
the establishment of purulent foci, caused by phlebitis and re-absorption,
which I saw fatal in two patients in 1824 and 1825, at the hospital of the
School, is maxie much less probable. I do not know, indeed, whether tlie
cautery is really indispensable. The branches of arteries divided are so
small that at first sight it would not appear that opening them could prove
dangerous. When left to themselves these vascular mouths will probably
very soon cease to flow ; and I should not be surprised if the very precau-
tions taken to guard against hemorrhage, were, in very many cases, the causes
of its production. I certainly think that they might be dispensed with in a
great many cases ; and that to prescribe them at first before the loss of blood
seems likely to be abundant, is an excess of prudence. What is there to pre-
vent us from resorting to it at a later period, if the bleeding should continue in
such a way as to create uneasiness ^ Nothing is easier when the wounds are
external. If they are deeper, the patient by a little straining will bring them
into view of the operator, who may then cauterize them without any difficulty.
Lastly, the use of the tampon should be a final resort, which there will
always be time enough to call to our assistance. Two patients whom in
18S1 I treated in this manner, had no cause to regret its having been
adopted.
jirt. 4. — Falling doivriy Procidentia, or Prolapsus of the Rectum.
Falling down of the fundament is an occurrence not to be confounded with
psTcidentia through the anus owing to intus susceptio of a higher or lower
portion of the bowel of greater or less extent. The one depends on relaxa-
oyZ NEW ELEMENTS OF
tion of the mucous membrane of the rectum, the latter, on true intestinal inva-
gination. The former alone, calls sometimes for the aid of particular operative
proceedings. In children with whom it is very common, the progress of age
and the use of proper topical applications, will generally overcome it. Not
so in adult age. Its obstinacy then often becomes a source of trouble to the
surgeon and of despair to the patient. When the tumor only shows itself
after every stool, and then easily returns afterwards, it becomes certainly an
extremely distressing complaint, though it does not endanger existence;
whilst, if the patient cannot succeed in reducing it, it may become strangulated
by the action of the sphincter, inflame, sphacelate, and give rise to most
alarming symptoms.
Reduction. — To reduce this tumor, we act precisely as in cases of inverted ^
uterus and vagina. The patient lies upon his back, the breech being raised
higher than the abdomen, and all the muscles in a state of relaxation ; the
rectum is to be wiped off with tepid water, then rubbed over with a mixture
of oil and wine ; it is then wrapped up in a piece of fine linen, and then com-
pressed gently from circumference to centre, from above downwards with the
palms of the hands, or the fleshy parts of all the fingers ; whilst the patient is
prevented as much as possible from making any eftbrt. Sometimes we suc-
ceed better by pressure on the centre of the mass with the tips of several fin-
gers united to form a cone, as if to enter the anus, pushing before them the
compress with which the tumor has been capped, and which is held on by the
other hand. The operation is not over when the tumor is replaced. A large
pledget, with or without a chemise, is frequently used as a means of keeping
up the reduced part. A tampon of lint contained in a linen purse, a globe or
oval of ivory, wood, or gumelastic ; in the female a pessary in the vagina,
astringent glysters and hygienic cures, are the means to be essayed for pre-
venting its return.
Division of the Sphincter. — If the reduction of the prolapsus be absolutely
impossible in the ordinary way and danger threatens, we must not hesitate to
divide the sphincter ani on one or both sides of the root of the tumor. This is
to be drawn on one side with the left hand, whilst with the right hand and a
straight bistoury, the integuments first and then the fleshy ring are to divided,
beginning nearest the intestine, that is, from within outwards. An operation
of this kind by M. Delpech on a young person in 18S0, was attended with
complete success. '
Excision. — When nothing prevents the parts from reascending, and yet, in"
spite of every endeavor they refuse to do so, the only remedy known thirty
years ago, and the only one now known by many authors, as able to be per-
formed for the* affection, is removal. It is an excision or a resection, which in
itself is easy enougli, and is performed in the same way as the removal of
degenerated piles, a polypus, or any other tumor with a tolerably large base.
It is unnecessary, however, to take out the tumor from quite within its root.
If the two upper thirds are destroyed, the remainder will inevitably re-enter.
It is possible that the success of the operation would be equally certain if the
mucous membrane of the rectum were alone attacked and its muscular one
respected.
The dressings, and the consequences of this operation, are scarcely different
from those which have been detailed under the head of hemorrhoids.
OPERATIVE SURGERY. 89S
This is, as may be seen, a cruel procedure, and one which is very far from
always succeeding. Happily modern surgery almost always avoids it: sub-
stituting for it a method much less alarming and less painful, and on the
whole, quite as certain ; the only objection to which is, that it is not applica-
ble to irreducible procidentia, and can be exerted only upon the tumor after its
restoration has been once effected.
Procedure of M. Dupuytren, — This consists in the excision of the radiated
folds, which are observed upon the margin of the anus, whether they be, or
be not the seat of hemorrhoidal tumors. In a majority of cases, it certainly
appears that dilation of the sphincter is the great obstacle to the cure, or else
the very great relaxation experienced by the mucous membrane and integu-
ments which follow it outwardly. The cellular tissue which lines them,
acquires such looseness after a time, as to allow them to slide with wonderful
ease over the layers which they cover naturally ; and whose motions in a
st;ate of health, they are content to follow. The removal of a certain portion
of the cutaneous layer, surprisingly rectifies this anomaly and defect, and
thus becomes almost an infallible remedy for the evil which is its frequent
sequel.
The idea of the operation first occurred to Mr. Hey of Leeds, in 1788, in
the case of a Mr. W. of Hull, who had previously been a patient of Sharps,
and in whom the anus continued to be surrounded, after reduction of the pro-
lapsus, by a thin pendulous cutaneous flap, which was eight or twelve lines
long, and had at its base and within, several bluish and soft tuberqles, such
as are seen in persons who have long labored under piles. '*It appeared to
me," said he, " that the prolapsus depended on the laxity of the very lowest
part of the intestine, and of the cellular membrane which connects it with the
surrounding tissues." For the author this remark was a ray of light. He
conceived that to cure his patient, he had only to increase the adhesion of the
tissues surrounding the anus, and the action of the sphincter itself. The
surest way of accomplishing his object seemed to him to be to excise the
tegumentary flap with its appended tubercles. He was in hopes of causing
thereby an inflammation which should be capable of producing a firmer adhe-
sion of the rectuHLto the circumjacent tissues, entertaining no doubt that a cir-
cular wound must bring with it a more powerful constriction of the sphincter
ani. Mr. Hey accordingly removed the pendant rim and the bluish tumors
by a bistoury. This operation he performed on the IStli November, and in
March 1789, M. W. wrote him word that his cure had continued uninter-
rupted. A second patient operated on in 1790 in the same way, recovered in
three weeks ; in him excision was performed only on one side. In the month
of April 1791, Mr. Hey a third time put his plan in execution, removing the
pendant flap and encroaching about a quarter of an inch upon the red mem-
brane which covered the anus. His success was as great in this as in the two
other instances. He treated a lady in the same way in 1799, except that he
removed the two soft tubercles seen on either side of the anus at different
intervals of a certain time. She also recovered, and in as short a time. Yet
even at home, the success of Mr. Hey remained unremembered, and Mr.
Saml. Cooper, who mentions it, speaks of it too vaguely for any one to derive
much benefit from it; and but that M. Dupuytren entertained similar ideas,
devised a method, and made that method general, it would probably have
excited no more attention in France than it had before in England.
894 NEW ELEMENTS OF
Tlie Operation. — A gljster and some mild purgative is to be given the pre-
ceding night. The patient is placed as for tlie excision of hemorrhoids. The
surgeon, with good forceps, successively seizes each radius which he means
to remove, and excises it with verj sharp scissors from below upwards, begin-
ning at the margin of the anus, at about an inch from the sphincter, to end
some lines above. According to the account given of it by mj old fellow stu-
dent, M. Paillard, in the Journal Hebdomadaire, M. Dupuytren states that
four radii are sufficient to remove ; one before, one behind, and two laterally.
I have thought proper to remove six in one case on which I operated, and
eight in another, because of the relaxation of parts and great dilation of the
anal opening. Of course, every ribbon cut away may be made larger or
smaller. The solution is begun more or less low, and ended at a greater or
less height, according to the state of parts. One of Hey's patients had
hemorrhage. I do not know that any of Dupuytren's met with this accident.
The English surgeon having left us no detail of his proceeding or his subse-
quent dressing, &c. we are left in ignorance whether the bleeding was owing
to the operation itself, or the way in which it was performed.
The Professor at the Hotel Dieu merely covers the wounds with a soft mass
of lint spread with cerate, and either places no tent at all in the anus or a
very small one. Twice I have pursued a different course. I passed in a tent
as thick as the finger to some depth in the rectum. I separated several little
fasciculi, placed them between the edges of each wound, and kept them apart
by means of lint, thin compresses and a T bandage. My intention was to
prevent an immediate union of the small wounds, to compel them to suppurate
that I might obtain a modular cicatrix of more firmness and elasticity, and
more solid adhesion than would have followed the original union. I have had
no cause to repent of having done so. The recovery was complete; but I
must admit that M. Dupuytren's method which is more simple, must be al-
most quite as good a one, for his patients have all equally been permanently
cured of their infirmities.
But any one who knows the difliculty of prolapsus ani and the trouble
which it gives, this operation, which I have now described, must be consi-
dered a valuable triumph of modern surgery. One of the things which made
a great impression on me, when I arrived in Paris in 1820, was a successful
case of this kind. I could scarcely conceive how it could be possible that a-
woman then lying in one of the surgical wards of the Hotel Dieu, who for
fourteen years had never gone to stool without having the rectum to prolapse
under the form of a red livid tumor, as large as the two fists, should be imme-
diately cured by the removal of a few folds of integuments. It was done,
however, and to my great surprise. M. Paillard states that this operation has
now, in fifteen years, been often performed by M. Dupuytren, and has failed
but once: and even that single failure may be attributed to the course
adopted. For my own part, I have performed it but twice upon two women,
at the Hospital St. Antoine ; and its effects were no less satisfactory.
When the prolapsus recurs at the first stools, which are discharged after
excision, it is seldom so decided as before, re-enters of itself with more or less
difficulty and soon finally disappears. Looseness of bowels is favorable to its
success, as it prevents the patient from straining so much in defecation ; and
must, consequently, be promoted by injections, mild purgatives, and laxative
OPERATIVE SURGERf. 895
drinks. Finally — Excision of radiated folds of integuments around the anus
would appear to be sufficient to remedy all cases of procidentia, which de-
pend on a state of relaxation of the mucous membrane, integuments,
sphincters, and outer tissues ; indeed, in any case not originating in organic
lesion, or disorganization of any of the parts contained in the pelvis and hypo-
gastrium. Amputation of the mass should be reserved for cases of intestine
prolapses owing to inversion or intus-susceptio and those procidentiae which
are absolutely irreducible.
Art. 5. — Fissures,
Amid the small wounds and ulcers which appear about the anus, one
species exists, the only remedy for which thus far, lies in a surgical operation.
I mean those cracks .or chops so obstinate and so painful, which exist in the
tegumentary folds of the anal circumference, which doubtless, from their fre-
quency, must have been often seen, were mentioned by Avicenna and others,
who gave them no characteristic distinction, and by Lemonnier more expressly
in 1661 ; for all which, however, they continued to be confounded with
chancre and syphilitic ulcers, until M. Boyer first showed their real character
and pointed out the true mode of tr^ting them. Whether this be the result,
as M. Boyer thinks, or the cause of the spasmodic contraction of the sphincter
which is seen to coexist with them ; whether caused by the pipe of a syringe,
as M. Thebord says he once saw at Besancon, or by the passage of hardened
and irregular feces, it is pretty certain that they are seldom, if ever, relieved
by any topical application. The Belladonna ointment, spoken of by M.
Vivent, and which M. Dupuytren uses, though it may sometimes cure oftener
disappoints the expectations of those who use it.
The oil of Hyoscyamus given internally, combined with the introduction
of mercurial ointment into the anus, as M. Descude advises, is not so far as I
can learn more uniform in its effects. The same must be said of nitrate of
silver, extolled by M. Delaunay, and used with some benefit by Beclard ; it
has failed completely with M. Richerand, and I have not been more fortunate
than him with trials I have made with it. Opium and cold water which others
praise very much are effectual in but very few cases.
Excising the ulcerated surface, which has long been proposed and practised,
will generally cure them; but incision is generally so satisfactory in its
results, and so commonly known now, that, admitting the knife to be ne-
cessary at all, it seems useless to follow any other than the advice of M.
Boyer.
The Operation. — Its necessity is pointed out whenever the patient com-
plains of burning pain at each stool, as if a red hot iron were being passed in
at the anus ; if he suffers but little in the intervals ; when the sphincter is
so much contracted, as without being disorganized to allow the forefinger to
pass only with pain and difficulty; and this, whether the fissure be visible or
not; whether it be detected by the finger in the anus or not. The prepara-
tions, position of patient, surgeon, and assistants, are the same as in the opera-
tion for removing hemorrhoidal veins.
Every thing being in readiness, the operator passes tlie forefinger of his left
haiid into the rectum ; introduces on it, flatwise, a narrow, straight, probe-
896 NEW ELEMENTS OF
pointed bistoury, held in his right hand above the sphincter ; then turns its
edge towards the fissure, if he can detect its seat, if not, towards one buttock;
has the skin made tense by the fingers of an assistant; then cuts from within
outwards the constrictor muscle, in all or nearly all its thickness, being care-
ful to extend the cut on the integuments towards the buttock and a little
towards the interior of the intestine. When we do not know where the fissure
exists, that there is a fissure at all, or if the disease does not arise wholly
from spasmodic constriction of the sphincter, M. Boyer advises us to make an
incision on each end of the transverse diameter, and never on its antero-pos-
terior diameter. Even though success do not appear less certain, it is still
more prudent to carry the bistoury forwards or backwards, when the crack is
situated there, than always to cut on one side at the risk of leaving it un-
touched.
The only difficulty which is to be overcome, arises in some persons from
the softness of the tegumentary layer, either mucous or cutaneous, and its
disposition to get away from the dividing instrument. To conquer this, it is
very necessary to see tliat the parts are well stretched. The sphincter, as it
offers much more resistance, may be cut with much less effort. Should it be
noticed that the inner coat is not cut into, as high up as the subjacent tissues,
we must, unhesitatingly, extend the se(^tion upwards with straight scissors;
whilst the bistoury would be a fitter instrument for enlarging that of the skin
downward, if it were necessary.
A tent of moderate size, a square cushion of lint, some compresses, and T
bandage suitably applied, constitute the dressings. From the termination of
the operation, the lacerating and distinctive pains of the fissure, are changed
to those of an ordinary incision; and after the very first stool, the difference
is so very marked, that most patients are astonished and delighted. The
wound heals by degrees. The dejections resume their primitive regularity.
The patient again enjoys the pleasure of repose, and after the cicatrization
which is effected generally in less than three weeks or a month, he is as free
from all suffering as any one else. Some instances of its failure have been
mentioned, but so vaguely detailed as to admit of no conclusion from them.
I have never seen it fail in producing its effect. In 1829, it suddenly arrested
the agony endured by a woman upon whom I operated at the hospital St. An-
toine, which neither dilation, caustic, opiates, or belladonna could allay. How-
ever, I am constrained to remark, that two patients upon whom it has since been
performed have died of it; and that the incision, which in one was healed
entirely and in the other nearly so, had not prevented the formation of
several abscesses in the pelvis, about which slight traces of peritoneal inflam-
mation were also visible.
Art. 6. — Fistula.
Fistula is one of the most frequent of the diseases which affect the anus, it
is also one of the most serious, and has been the most spoken of by authors.
Every species of treatment has been opposed to it. By Purmann it was cured
by lime water injections, calomel, alum, &c. Pledgets of lint, good living,
and detergent injections, answered for pallus. Evers, quoted by Sprengel,
was in some cases equally successful with injections of gum ammoniac. If
OPERATIVE SURGERY. 897
Titsing be believed, digestive (irritating) ointments do very well. It is
known that in the time of Dionis, the waters of Barriege and of Bourbon, and
some particular liquids and unguents were extolled as of like effect ; but the
personal experience had of them by Louis XIV, who himself was the subject
of fistula in ano, very soon reduced these panaceas to their proper level.
Caustic, which enjoyed greater popularity, and is in fact, of greater efficacy,
is mentioned by the oldest authors, and was used in practice under all its
forms.
The surgeons of Alexandria employed a linen tent, steeped in the juice of
the Euphorbium (lithymale), and dusted over with flour of copper (oxides and
sulphate). Leonidas advises the use, on timid patients, of pledgets of lint
spread with litharge, or some other catheteric substance. Sublimate and arse-
nic had each their day, and J. de Vigo knew of nothing so excellent as a tent
covered with vermillion. Fallopius gave the preference to the Egyptiacum,
and to precipitate. Lemoyne, who lived in the seventeenth century, made
himself famous by a corrosive ointment, which he spread on a linen tent.
*' He," says Dionis, ** died rich, because he would always be well paid ;
wherein he was right, for the public value things only in proportion to their
cost. They who dreaded the knife, placed themselves in his hands, and as
the number of cowards is very large, he did not want business." For this
reason the actual cautery, used by Albucasis, and which D. Scacchi and M.
A. Severin dared scarcely to advise, must have obtained the less favor.
Although it may sometimes be successful, this method is now wholly aban-
doned ; as is also that of Roger of Parma, which consisted in producing ab-
sorption of the callosities with fistula by tents arranged with threads.
§ 1. Anatomical Remarks.
As concerned in the operation for fistula, the rectum and perineum require
to be examined in another point of view than for that of cutting for stone.
The skin as it converges towards the intestine, wrinkles and forms plaits,
which are repeated on the mucous membrane within the sphincter, and even
extend quite up into the pelvis. Small valves, their concavity being upward,
which are to be seen occasionally crosswise between them, give rise to capulse
somewhat resembling pigeon baskets, in which irregular bodies mixed with
feces, are easily arrested, in which small abscesses at times originates, and
which becomes the starting points of a good many fistulae. The tegumentary
and mucous membranes, which are united by a very mobile and yielding
cellular layer to the subjacent laminie, become detached with great ease, and
slide backward and forwards upon the other tissues and purulent sinuses
which attempt to pass between their outer surfaces and the neighboring ele-
ments. The venous network which covers them without, more abundant and
better sustained within the ring of the sphincter, is generally compressed
above by the accumulation of fecal matters, and by being irritated and sub-
jected to friction during defecation, becomes congested, hypertrophied,
changed into erectile tubercles, suppurates and ulcerates, and hence arises
another disposing cause of fistula. The intestine, which is flexible and dila-
table above the constrictor muscle, where it is supported neither by the point
113
898 NEW ELEMENTS OF
of the coccyx, or by the aponeurosis, and which is obliged to lean backwards
so as to follow the curve of the sacrum, and make room for the bladder, here
presents a species of dilation, the lower half or floor of which is necessarily
obliged to bear the action of all the solid and irritating matters which endea-
vor to escape from the digestive passage ; which is a third cause again of the
occurrence of fistula. As its posterior wall alone suffers this inconA^enience,
it is natural that most fistulae should have their roots posteriorly. This por-
tion of the organ is supported below by the fascia pelvica or the levatores ani
muscles, and ischio-coccygean ; whence perforations in it are more likely to
be attended with an effusion of pus into the pelvis than any otlier. The peri-
toneum by quitting its sides that it may line the interior of tiie pelvic cavity,
leaves all its posterior edge in close contact with the cellular tissue, which is
continuous in the thickness of all the mesenteries. Consequently it is
possible that pus, forming on the forepart of the spinal column in the lumbar
regions, or even in the thorax, may comedown, following the posterior face of
the rectum as far as the perineum, give rise to an abscess on the margin of
the anus, aud create a mistaken belief in the existence of an anal fistula, a
remarkable instance of which came under my notice in 1825, at the Hospi-
tal de Perfectionnement.
The Aponeurosis m^j be considered as forming two distinct systems around
the rectum. The outer of these comprises, 1st, the parietal portion of the
fascia pelvica, i. e. that which covers the obturator and pyramidal muscles in
tlie pelvis, 2d, the ischiatic layer of the ischio-rectal aponeurosis of the per-
ineum, which inferiorly completes the fibrous canal of the obturator internus
muscle and on the one side is continuous with the sacro-sciatic ligament, and
on the other it closely approaches the inner border of the preceding layer.
Taken all together, this system resembles a large vault, fastened by its edges
upon the two straits, filled up by the above mentioned muscle ; the two planes
of which vault incline towards each other, and so unite as to form as it were
but one edge at the moment of tlieir injunction. To the other system belongs
both the cellulo firbrous layer, which ascends from the bottom of the pelvic
excavation up over the outer surface of the intestine ; and the rectal leaf
of the perineal excavation which lines the surface of the levator ani and the
ischio-coccygeus. These two layers compose the second vault, whose con-
cavity is turned towards the rectum, continuous outwardly with the inner edge
of the outer vault. Perforations of intestine or pus can get beneath the peri-
toneum into the pelvis, only by traversing its upper or pelvic layer; and into
the ischio-rectal excavation, only after passing through its lower or perineal
layer. All fistula which originate between its anal edge, that is to say, above
the sphincter and its upper edge, i. e. below the peritoneal cul-de-sac, make it
possible for both these modes of propagation to be followed ; and expose to
the formation of burrowings of matter backwards, between the anus and
coccyx, and also, between the fibres of surrounding muscles, being pressed
downwards, jj;enerally only by reason of the pressure of the intestines, or the
inconsiderable resistance of the interior aponeurosis. Such as have their
origin a little further down, on the contrary, immediately enter the ischio-
rectal excavation, and are but little disposed to spread towards the pelvis.
However, the circumstance of the anus being embraced by the fascia, as it
OPERATIVE SURGERY. 899
were by a ring between the sphincter and the intestine, explains the way in
which fistula that have originated at this joint and opened externally, are so
frequently complicated with detachment either of the mucous membrane or
of the whole thickness of the rectum for an extent of one to several inches
upwards. The enormous quantity of fatty, cellular tissue placed between
the thin and the perineal vault of these two systems of the aponeurosis, is
consequently the usual locality of those stercoral inflammations which pre-
cede the establishment of fistula in ano. It is so much the easier destroyed,
either by gangrene or suppuration, as it forms an almost isolated mass in the
back, part of the perineum; and the vacuum which it produces is filled up
with the greater difliculty, that the ischiatic layer of the excavation is
immovable, andean no sooner approach the denuded intestine, but the natu-
ral action of the rectum interferes to separate them again. This is no doubt
the reason of the frequency of blind external fistula, erroneously denied by
many modern writers, and of those changes to fistula of abscesses which
either do not communicate at all or only secondarily with the anus.* Hence,
also, arises the disposition to spread which is observed in deep phlegmonous
abscesses, to open into the intestine and to produce a blind internal fistula,
instead of tending outwardly to the skin. In fact, the rectum, which is
always flexible, and very frequently empty, often presents less resistance to
them than the skin; besides which, the organism has here no excentric pres-
sure of the viscera, as in the parietes of the abdomen, to oblige the pus to
pass towards the exterior. The train laid by the cellular tissue above the
coccyx and lower edge of the gluteus maximus muscle, perfectly explains
the vast cavities which in certain persons are seen in this direction ; and its
continuity with the lamellar tissue of the meso-rectum, also explains how an
abscess may be caused on the margin of the anus by disease of the sacrum,
vertebra, or bones of the pelvis, which may simulate a fistula by extending
above the transverse muscle, in the anterior cul-de-sac of the ischio-rectal
excavation in man, or in the thickness of the labia majora in woman ; and
thirdly, how it is that abscesses can make their way through the perineum
towards the scrotum, and produce fistulae which might at first be supposed to
be of an urinary nature. Lastly, it is by following these different tracks
that certain fistulae open so far from their point of departure, and perform so
complicated a transit.
The arteries are all likewise worthy of some attention. The trunk of the
internal pudic is at too great a distance to run any risk at the time of the
operation, unless it is necessary to make very large lateral sections. The
inferior hemorrhoidal, which it gives off" behind the ischium, though often
interested, need give no anxiety. They are too superficial, generally too
small, and too easy to find, tie, or make pressure upon, for the surgeon really
to be afraid to wound them. The branches given by the hypogastrics are
likewise .too delicate, and are distributed to points too distant from the skin,
to be reached by the instrument. The median hemorrhoidal, which form the
inferior mesentric at their termination, demaid a little more respect. Situa-
ted posteriorly, at first between the lamina of the mesentery and afterwards
in the very thickness of the fleshy layer of the intestine, they approach
nearer and nearer to the mucous tunic, and continue to be of same size in the
laced or net work which they form around the cutaneous extremity of the
900 NEW ELEMENTS OF
rectum. Owing to this arrangement, their section is more dangerous in the
posterior half of the organ, than in the opposite direction, and also the higher
the operation is performed. From the foregoing remarks, it follows that the
greater number of fistulas in ano being preceded bj phlegmonous abscesses in
the ischio-rectal excavation,or by hemorrhoidal tubercles must arise within the
sphincter, between it and the fibrous ring which exist above, or the pyloric
valve described by Mr. Houston. The first person who seems to have made
this remark is Mr. Brunei in 178S, or at least M. Pleindoux has since then
claimed it for him. But it had not escaped either Sabatier, or M. Larry;
although to M. Ribes is due the credit of having established it as a principle.
This latter author has, however, gone evidently too far in saying that, no
others are ever met with. The hundred cases upon which he founds his
opinion, however imposing a mass of authority they be, cannot destroy the
opposite facts, detailed by other practitioners. M. Boyer and Roux, state
that they have operated on fistula, the orifices of which were several inches
in depth in the intestine. I treated one myself whose orifice was so high up
that it was with difficulty I could reach the spot in the intestine with my
finger; and in a patient who died in 1825, at the hospital of the school, it
opened backward at three inches above the sphincter. These very elevated
fistula, are owing to the impaction of foreign bodies in the dilatable portion
of the rectum, and to this list also often belong those cases seen in phthisical
patients, the frequent result of tuberculous ulceration of the folliculi or
lacunae of the organ. It is incorrect, however, always to judge of the depth
of a fistula, by the vertical extent of the detachment effected ; the stylet will
often enter without difficulty three or four inches, though the fistula may be
seated at a depth of only as many lines.
§ 2. Examination into the Methods.
A. Ligature, — Caustic, injections, and the apolinosis or ligature,which accord-
ing to one of the books attributed to Hypocrates, used to be made with five
threads surrounded by a horse hair, and was passed through the fistula into the
intestine with a brass stylet, have encountered the same fate and are now
very seldom employed. In the time of Celsus a kind of packthread was used,
which was spread with some escharotic substance. Avicenna preferred
twisted horse hair or hog's bristles. Guy de Salicet. advises the use of a
small string, knotted in several places, to cut the parts; whilst Guillemeau,
an imitator of Pare, passed it through a canula by the fistula into the rectum
with a double edged needle. Notwithstanding the reasoning of Foubert, who
substituted a leaden wire for that generally in use, and who contrived, for the
purpose of introducing it, a stylet of a rolling-pin shape ; of Camper, who
returned to the use of silken or hempen ligatures; of J. J. Bousquet, who
recommends that the lead wire be surrounded with lint and passed with a
needle; of Desault who employed a directing catheter, then, like Pare, a
canula, and also a leaden wire, which he seized in the intestine with his finger
or gorget-forceps, to draw its extremity out at the anus, and fasten it by means,
of a knot tightener; of Flajani, who was satisfied to use a waxed hemp liga-
ture; and, indeed, of most timid surgeons, Apolinosis numbers but few advo-
cates among the practitioners at the present day. The advantage attributed
OPERATIVE SURGERY. 901
to it by its advocates are more apparent than real, and are counterbalanced
by numerous inconveniences. Its action is very slow. The strangulation
which it causes often gives the greatest pain, and nervous contractions, which
are really such as to create uneasiness. It will cure complicated deep and
multiplied fistula but rarely ; and even in the simplest cases is far from
always proving sufficient.
The Method of Operation. — If, however, we wish to attempt it, it is imma-
terial whether we use a strong well waxed thread of linen or silk, or a wire
of lead or pure silver. If the first, we pass it through the fistula by means
of a sharp flexible stylet ; and if the second, we introduce it through a grooved
staff or canula; the forefinger of the left hand in either case, being pushed
up the rectum, seizes on the thread or wire and draws it out at the anus.
The ends are then to be placed in the ball knot tightener of Riolan, Gerauld,
or still better, that of Mayor, or else in Desault's instrument, or they may be
twisted on themselves, if of a metallic substance. By being careful to tighten,
them, as the tissues give way, say every day, or only every two or three days,
as the constriction remains greater or is lessened, one mav succeed in cutting
through the intervening tissues in twenty, thirty, or forty days, so that by the
time the ligature is out, the fistula is generally healed. But how many times
does it become necessary to remove it before this is accomplished, owing,
to the pain it produces, its slow mode of action, and because patients cannot
endure it. In 1 824, M. Bengon determined to give it a trial at the Hospital
de Perfectionnement, upon a courageous and stout adult. The man kept it
in for three weeks, complaining of excessive pain each time it was tightened.
By the end of this time, the frenum, though of trifling extent originally was
not half divided, and as the sufferings increased, it was thought proper to ex-
cise it, which was speedily successful. Taking every thing into consideration,
ligature, being applicable only to superficial simple fistula, should be given up ;
and with less regret, because the methods which can be substituted for it, are
generally less painful, and as easy as they are safe and certain.
Eccentric Compression. — All surgeons have not yet relinquished the idea of
curing fistula without shedding blood in the operation. A means has indeed
been conceived of late years which appears to be highly ingenious, the object
of which is to close the inner orifice and thus dry up the ulcer. The idea which
belongrs, I believe, to M. Bermond also occurred to M. Colombe. The first
gentleman conceives that this end may be perfectly accomplished by his double
chemise canula, applied as we described when speaking on piles : the latter
assures us, that he has succeeded in doing it by keeping a hollow ebony cylin-
der in the anus held by ribbons without. The method may be tried ; but
it is not yet sanctioned by experience, and too much is not to be expected
from it. From an attempt made by the author, it is proved that the mucous
membrane of the rectum may become invaginated in the upper aperture of the
compressing body and give rise to acute pain. The cutting instrument then
alone remains which is capable of adaptation to, and triumphing over every
species of anal fistulse.
B. Operation properly so called.
Incision and excision, which have alternately been rejected, the one for the
902 NEW ELEMENTS OF
other, and vice versa, are now alone retained in practice, having undergone
many changes and improvements; but in such a way, that now, far from being
materially incompatible, w^e often require to combine the two methods, and to
employ them in concert.
1. incision. — In spite of their predilection for caustic and ligatures, the an-
cients very well knew that incision was the best remedy for fistula in ano.
Hippocrates says so in so many words, and it is further sufficiently evinced
bv an instrument called Syringotome, a kind of sickle-shaped bistoury, which
was employed in the time of Galen. By Leonidas it was performed with an
instrument, whicli ended by a long flexible stylet, which was introduced into
the fistula and brought out at the intestine so as to cut the frenum at one stroke.
In the middle ages, Hugh de Lucques, first passed a ligature to act as a staiF
and make the parts tense during the incision. Guy de Chauliac, who was
always alarmed at the prospect of hemorrhage, preferred a grooved staif or di-
rector, upon which he guided his bistoury, heated to whiteness. Fabricious ab
Aquapendente, having dilated the passage with his speculum, employed merely
a simple probe-pointed bistoury rather concave, and a staff, for making the
incision. Among others, Sphigelius, for example, contrived to encase the syrin-
gotome in a curved silver probe-pointed canula which entered first into the
fistula, was withdrawn by the fingers, leaving a wire attached to the end of the
bistoury, to draw it forward both by point and handle, and divide the fistula at
one stroke. Marchett conceived the idea of passing a conducting gorget into
the anus for the purpose of receiving the point of the cutting instrument, or of
the director. Wiseman dispensed with it, and employed scissors instead of the
syrino-otome, which did not, however, prevent Felix from reproducing Leoni-
das's bistoury, which he altered by covering it with a cap so as to make its
introduction less painful. This instrument subsequently received the name of
"rovai," owing to the operation performed with it on Louis XIV. During the
last century, J. L. Petit demonstrated tliat a common bistoury, slightly con-
cave, passed upon a grooved staff, was equally as good as any apparatus
before extolled ; and Ringe made the process as certain as it was possible by
advising a gorget like that of Marchett's, and a grooved staff, one introduced
into the intestine, the other through the wound, so that by means of a long
straight, strong pointed bistoury, made to slide upon the staff", all the parts
contained between the two instruments might be divided.
2. Platner thought that he had improved the mode of incision, by proposing
to effect it by a bistoire cache, which others generally combined with the gor-
get. Pott, to simplify it, still further considered that all that was necessary
was a curved probe-pointed bistoury. For this B. Bell substituted a narrow
bistoury ending by a beak like a catheter. Pott's instrument was modified
almost immediately by Savigny, who fixed a pointed blade upon one of its
faces, which might be made to draw in and push out at will ; and also by T.
Whately, who made its cutting edge movable, so as only to draw it after
the knob on its blade had been carried into the rectum. Some persons in our
own times have resorted to the use of this bistoury; Dr. Dorsey caused the
point to be lengthened out into a cone; and M. Dubois makes it advance upon
a grooved flexible staff which is previously brought from the intestine out at
the anus, by the finger. M. Larrey adopts the old stylet bistoury of Leonidas,
reproduced by H. Bass, and afterwards by Brunei. In the way that it is
OPEIL\TIVE SURGERY. 90S
modified by this surgeon, it is no other than a common straight bistoury, end-
ing in a long, blunt and flexible stylet, which is pushed in at the fistula, and
drawn out at the anus, no other conducter beino; needed for dividins at one
cut the whole thickness of the frenum. Lastly, I have been shown one by M.
Charriere, the back of which is grooved in such a way that it slips as well
upon a cylindrical stem as upon a grooved staft', so that the exploring stylet
generally employed becomes its guide; the substitution of the sound for it is
not required.
AVithout attempting to deny the success claimed for each of these numerous
procedures, it may at least be asserted that out of the whole armament, the
only instruments worth preserving are those which have been kept in use by
modern surgeons ; viz. the wooden gorget, the grooved staff, the straight bis-
toury. Pott's bistoury, or the bistoury of M. Larrey.
2. Excision. — The mode of performing excision has likewise varied. It is
first described by Celsus. " We make,*' says he, *' an incision on either side
of the track, and remove all the parts which they enclose between them. "Paul
of Egina, resorted to the syringotome, forceps, and an ordinary bistoury. Some
have been content to excise all the movable wall of the fistula, after having
included it in a loop of thread, &c., or raised it up with forceps or a director,
and for this end, employed either the straight or concave bistoury, or curved
scissors, as recommended by G. Heuermann. Others thought it requisite to
remove the whole track of the fistula, either at one stroke, or by excising the
two walls one after the other. Some, the vault being once destroyed, were
satisfied with merely scarifying simply and purely its callosities. Those as
MM. Boyer and Roux, who now admit of excision, begin by an incision into
the passage, and then remove the detached integuments which they take up
with forceps, and cut away with strokes of the bistoury,
T7ie Method of Operation. — A purgative given over night, if the state of the
digestive organs permits, is necessary to prevent the want of an alvine dejec-
tion from being too soon felt. Dionis says, that a "glister should be adminis-
tered two hours beforehand, that the surgeon may run no risk during the
operation, of having his face inundated with fecal matters."
The instruments are the particular kind of bistoury which may be preferred
several common bistouries, strong dissecting forceps, a silver and a steel di-
rector, the latter without any cul-de-sac, a boxwood or ebony gorget, straight
scissors, scissors curved on their flat surfaces, some irons for cautery, needles,
ligatures, along tent of lint, and a tent-bearer, (portemiche) to passitin with
tampons, or the hoemostatic contrivances elsewhere described, (see excis. of
haemorrhoids), some balls of lint, three or four square cushions of lint, long
compresses, square compresses three or four times doubled, and a double
T bandage.
The patient, when the fistula is upon the nigh side, lies upon his right; on
the contrary, upon his left side, when it is upon his left, in front or behind ; he
is to be doubled up, his head low, his abdomen resting upon a bolster, his lower
limb is stretched out, his upper one drawn up and flexed. An assistant stand-
ing in front, prevents him from raising his head, and watches over the motion
of his arms. The pelvis and the flexed limb are held still by a second assis-
tant. A third assistant, standing behind, is desired to separate the nates and
hold the gorget steady at the suitable time. Lastly, a fourth and a fifth are
904 NEW ELEMENTS OF
necessary to hold the other limb, make tense the tissues, and hand instruments,
or wipe ^e wound.
Before proceeding any further, the surgeon now seeks the two openings of
the fistula. The external one it can never be very difficult to discover. The
fecal moisture or the pus which escapes from it, is enough, with absence of
any wound, to point out its situation, though it should be at the bottom of an
hemorrhoidal tubercle, or some fold of integument. Not so always, however,
it is with the internal aperture. This is usually met with in the centre of a
small induration, shaped like the rump of a fowl (en cul-de-ponte) which the
forefinger in the rectum will often readily distinguish. It is often not found,
owing to our looking for it too far off; it is oftentimes so near the skin, that
attention is necessary to avoid overlooking it ; and it is not until all the stran-
gulated or right portion of the intestine has been carefully examined, that we
are to seek if it be not higher up. A flexible stylet, however, removes the
difficulty. It is carefully to be introduced through the cutaneous opening
with the right hand, in the direction of the sinus, and letting it follow its dif-
ferent tortuosities without effi)rt, its head will very soon present itself to the
left forefinger which is waiting for it in the rectum. When but one external
opening exists, this stylet penetrates generally with facility, unless the fistula
turn at several sharp angles in its course. When, on the contrary, several
are met with, and there are a good many burrowings around the anus, the dif-
ficulty sometimes becomes extreme. We must then pass the probe into each
separately, acting as aforesaid. Even should these attempts prove fruitless,
we are not authorized to conclude that no opening into the intestine exists.
Many circumstances may serve to conceal it from the observation of the sur-
geon. Some milk, if it were to be kept above the anus, would, by flowing out of
the outer wound, prove its existence, as it would, likewise, if, when passed in at
the latter orifice, it came out at the anus. Anv other inoffensive dark colored
fluid will do as well. It sometimes happens that the probe is separated from
xhe forefinger only by a pellicle as thin as a sheet of paper, and yet cannot be
made to pass bare into the intestine. It moves about in every direction with-
out difficulty. It is easy to feel that the mucous membrane is thin, detached,
and yet the probe is seen to remain outside of the organ. Is there, then, in
this case an opening at some different part, or is it a blind external fistula ?
It is impossible to say, and yet something must be done. These cases which
were formerly thought very embarrassing, and which are still exceedingly
disagreeable to those surgeons who do not think it right to operate, without
having first passed through the fistula from one side to the other, are not, in
the eyes of M. Roux deserving of all this solicitude. That surgeon, indeed,
asserts, that the inner orifice of the passage to be divided does not deserve
the importance which is usually given to it. The remedy is the same whether
it exist or not. Detachment of the rectum is quite sufficient to justify the
operation. The minute researches undertaken by the members of the Aca-
demy of Surgery, appear to him to have been nearly superfluous.
For my own part, I think, that although the means of ascertaining whether
the ulcer opens into the intestine, we should operate, nevertheless, though it
be not found to do so; since the disease has been of some months' duration,
and the defecator organ is to some extent detached.
If, then, we have discovered this aperture, and it is not very high up, the
OPERATIVE SUROERT. 905
silver staff is substituted for the probe. The forefinger seekin<^ it in the
rectum, hooks its beak, lowers it, and bending it a little, makes it come out
at the anus whilst the surgeon continues to push it forward with his right
hand. The whole of the intervening tissues are then divided at one stroke
by a simple straight bistoury, as is used by MM. Richerand, Ribes, Sa-
batier, and M. Dupuytren, and as I have often done it myself; or else
Pott's curved bistoury, that of Dorsey with a conical point, or the slightly
concave one of J. L. Petit; its point protected by an assistant, and conducted
upon the groove of the staff'. The whole operation is extremely simple.
When the fistula extends much Idgher up, or the detachment is carried very
far, it is better to imitate M. Boyer and M. Roux, and employ the steel di-
rector with a somewhat pointed beak. It is introduced to the upper part of
the abscess. Instead of the finger, which had followed all its motions in ano,
a gorget is introduced, and its groove offered to the beak. It is pushed into
this gorget in such a way as to pierce the intestine. By moving them back-
wards and forwards, which causes them to rub against one another, we assure
ourselves of their mutual contact. Thereupon, the assistant seizes the handle
of the gorget, holds it fast, and turns it outwards a little, as if he meant to giYe
it a seesaw motion. The surgeon does the same to the handle of the director
with his left hand; takes a bistoury with a strong point in his right hand;
places its tip in the groove of the director ; pushes it quickly on to the gorget,
and withdraws by raising his wrist and not allowing it to leave the fulcrum
which has been given to it. For fear that the whole IVenum has not been di-
vided, it is passed in a second and a third time upon the director; then to be
sure that nothing remains, the two co-operating instruments are withdrawn
together, as if they were but one. If there should remain a cul-de-sac at its
upper part, we are forthwith to proceed to divide the abnormal valve which
forms it, and lay it bare by means of scissors passed up on the finger. The
cutting edge of the bistoury is then turned outwards and applied to the bot-
tom of the wound, which it cuts or scarifies to a moderate degree in its whole
length, and which, moreover, it extends at the expense of the skin for an half
inch or an inch upon the buttock. Lest the integuments should be detached or
thinned, they are divided crucially or in the form of an inverted T ; alter which
each flap is to be seized with the forceps, and cut with the bistoury upon its
base, from the free surface towards the wound. But for this precaution suppura-
tion would be interminable and tlie cure very uncertain. The pain it gives and
the time it requires are nothing, in proportion to the advantages which result
from it. Prudence does not justify our dispensing with it, except in fistulae
of the very simplest kind.
The same that has been done upon one sinus of the fistula, is to be done
upon all the rest, so as to recombine them all with the wound of the rectum.
All the tegumentary portions thus formed, are equally excised though but
little changed, or though they may have lost all their thickness. The same
bistoury, or a probe-pointed one, still directed upon the finger, is, in the last
place, to separate each different frenum or valve, which exists at the bottom of
the sinuses or the wound, so as to make smooth, without abandoning it, all the
interior of the bleeding surfaces, and the operation is then over.
Tlie Dressings, but that the tent should be larger, are the same as those for
fissure in the anus. It is necessary after having introduced it, to place a
114
906 NEW ELEMENTS OF
large dossil between the lips of the wound, above which it should project up-
wards above an inch. Plenty of lint, with one or two square cushions of it
on top, fill up the margin of the anus. The whole is covered by two or three
square compresses, and as many long and rather wide ones. The two ends
of the T bandage, previously fastened round the abdomen, are brought down
over these different objects, passed between the thighs, crossed, brought back
in front, one on the right and the other on the left side, and knotted or pinned
upon the circular band round the abdomen, complete the apparatus.
Accidents. — Hemorrhage, if any supervene, is to be treated like that which
follows excision of hemorrhoidal tumors. The artery which yields it is, if
visible, to be tied with a ligature or twisted. If it is not, the pulp of
the finger is to be passed down into the wound, so as successively to compress
it at every point. As soon as chance conducts us to the vessel the bleeding
ceases* There, consequently, it is that we must apply small balls of lint,
dusted or not with some styptic powder or steeped in some liquid. The tent
and other portions of the dressings, are then applied as before stated.
If we do not succeed, and tamponing the whole bleeding surface does not
answer either, we may take our choice between actual cautery, Levret's blad-
der, Blegny's gizzard, Petit's tampons, adopted by Boyer, or M. Bermond's
apparatus, though such an emergency will be found to occur very seldom;
particularly as the bleeding which sometimes follows the operation for fistulJE
in ano, does good rather than harm, and almost always ceases spontaneously'
before it gets to be alarming.
Advocates for incision exclusively, do not pursue precisely the steps we
have detailed. Denudation of the rectum is not v^^ith them a sufficient reason
for extending the incision of it above the fistula. They maintain that after
the operation the intestinal wall again reapplies itself and grows fast to
the suppurating surface; that the same thing happens with the cutaneous
flaps and indurations, they do not fail to fasten again or to disappear, when-
ever the fundus of the fistula is a^ain continuous without an intermediate
frenum with the anus, and is no more than a groove or fissure in the intestine;
that the length of the operation is in this way much diminished, and very
much so the sufterings of the patient, and the time of the suppuration and
cure; that there is much less fear of hemorrhage and fever; that less defor-
mity ensues; lastly, that the important point is to interrupt the continuous-
ness of the sphincter, which, by confining the fecal matters, obliges them to
find their way partially through the track of the fistula.
To this reasoning it may be replied, that if, indeed, in a good many persons,
the thinned and denuded parts do ultimately grow fast again after mere
incision, the reverse is also not unfrequently seen. Why should it be
otherwise ? We see in this what we see daily in every part of the body.
No one at the present day has any doubt that the best way of treating an
endless host of cutaneous ulcers, is to cut away the thin and livid edges
which cover their fundus. Section of the sphincter is not always made. It
is not this muscle, in fact, but the fibro-muscular circle situated above, which
forms the most contracted part of the anus. And after all, what is it that we
fear? Loss of substance in parts as soft as these is soon restored. The
pain is less acute than is generally supposed. The parts owing to their being
thin, and as it were, dissected off*, contain no vessels of large caliber. Diffi-
OPEBATIVE SURGERY. ♦ 907
culty there is none to those who know how to direct a bistoury. In a few
seconds, every flap will be seized and excised. The patient whose mind is
made up to endure the operation, will prefer to suffer rather more and have
every possible cliance to recover certainly and speedily. On tlie other hand,
excision in this way is only done for fistulas which are attended with very
marked detachment. It bears only upon the skin, and the whole is confined to
pure and simple incision, when the passage to be destroyed is surrounded by
no disorganization. In a word, the indications which we are to fulfil, may be
considered as existing under two points of view ; 1st, to dry up the source of
the fistula by incising the rectum ; 2d, to put the wound into such a condition,
as shall conduce to its speedy and easy cicatrization.
Fistulae which open upon the anterior wall of the rectum require more car^
than the others. AVe must not perform excision of them without a very
manifest necessity for so doing. A bistoury carried up to their fundus with
this view, would soon reach the bladder, peritoneal cul-de-sac, or prostate, to
which risk the patient should not be exposed. AVhen they reach very higli up,
no matter in what direction, the operation is at once more difficult and more
dangerous ; not, however, for fear of wounding the peritoneum, though the
fistula reached to the sacrum; practitioners who have pointed out this risk,
having, doubtless, forgotten that the diseased aperture is only in the mucous
and muscular tissues, and not at all in the serous one; that the pus burrows
in the cellular tissue and not in the abdominal cavity; that if the peritoneum
were to be ulcerated there would be eff'usion into the abdomen, constituting
a disease almost necessarily fatal, or too serious at least to admit of thoughts
of any operation ; that as the bistoury is not at liberty to leave the groove of
the director which has been chosen for it, it is next to impossible it should
touch the peritoneum though the surgeon should make the atttempt, and that
every thing considered, there is not_ more to be feared from wounding this
membrane superiorly than inferiorly, in the front rather than the back portion
of the intestine. The danger arises from extending the incision beyond
the lower limits of the ischio rectal aponeurosis, or even the inner edge of the
pelvic aponeurosis, which gives rise to purulent infiltration between, first, the
two laminae and into the pelvis, and, secondly, between the peritoneum and
fascia pelvica. All tlfat precedes is to be understood of such fistulas in ano,
as are invariably kept up by some local vice, by solution of the cellular tissue,
or by perforation of tiie rectum. Such as result from caries, necrosis, or any
morbid alteration whatever of the ischium, coccyx, sacrum, or vertebrae,
which arise from deep seated suppuration in the belly or thorax, are nothing
but symptoms, whose causes must be removed before their cure can possibly
be effected. When modified by syphilis, or some morbific constitutional
affection, if we are desirous of operating, the patient should at least be at the
same time subjected to such general and specific treatment as the disease
indicates. It is to neglect of this precaution, that surgeons expose themselves
to see the w^ound obstinately continue open, and suppuration remain such as
they cannot dry up, though there exists no anatomical alteration which could
interfere with its cicatrization.
A rtile which experience has established, is that this operation should never
be performed on persons laboring under phthisis : 1 st, because most frequently
the fistulae retards the progress of the consumption : 2d, because it is usually
908
NEW ELEMENTS OF
produced by the ulceration of one of the thousand tubercles by which, like sieves,
all the organs are perforated ; 3d, because the wound will not heal, discharges
profusely, and reacts on the organism in a very dangerous manner : 4th, because
if by chance it does heal, it is observed that the disease, which is checked for
a moment, seldom fails to be much aggravated subsequently by it. This, how-
ever, is no reason for creating artificially a fistulse in ano in tuberculous
patients by passing a long instrument like an arrow per rectum, enclosed in
a stout canula whence it escapes when required, in such a way as to pierce
the intestine from within outwards, and from above downwards, emerging at
the margin of the anus, bringing with it a seton which is intended to be left
in the wound, as was proposed by M. Heurteloup, and I believe once done
by him at La Charite. This method offers no more advantages than would a
seton in the nape of the neck, or a blister to the arm. I even think that in
certain cases, by the pus which it furnishes to the general circulation, fistula
in ano may contribute to the production of tubercles, rather causing phthisis
pulmonalis, than acting as a remedy for it. The rarity of blind, internal
fistulae depends upon two causes : first, to their speedily becoming complete
fistulaj; secondly, to the ulceration, in the contrary case, being so slight as to
admit of their spontaneous cure. This I saw in a patient, in whom I was
obliged to open within the rectum, an extremely painful abscess, which could
not be detected from without, but which evidently projected into the intestine,
and whence more than a glass full of pus was discharged. To operate upon
this sort of fistula we endeavor to change them to complete ones, either by
placing a tampon upon the aperture for the purpose of retaining the pus
within, or else by means of a stylet curved like a hook passed per rectum, the
short branch of which, we endeavor to pass into the ulcer. These means
enable us to see v/ith what point in the perineum the burrow of matter cor-
responds, and to open it with one stroke of a bistoury. However it seems to
me, that havino; once discovered the orifice in the intestine, these researches
become unnecessary. The instrument carried flatwise on the finger, and
having a ball of wax on its point, would answer very well by cutting the
rectal wall of the sinus, from above downwards, and from within outwards,
as if we were treating an ordinary abscess, in such a way as to divide
the sphincter, if it be judged advisable. As to the question of the propriety
of operating on a fistula with the same stroke that opens the stercoral abscess,
as Faget advised, or whether it be not better at first to make on\y a puncture,
and defer the operation to a later period, which is the course advocated by
Foubert, it is now unanimously decided in favor of the latter writer : first,
because the introduction of the finger or gorget would cause too much pain;
secondly, because not being able to discover where the aperture is, nor how
far the detachment extends, it would be most frequently necessary to re-
commence the operation after some time ; thirdly, because many of these
abscesses, when once opened, get well without anything else being done, as
Foubert had already stated, and several instances of which I published
myself, and of which I have since then seen three other examples. Attention
to the dressings is a capital point after the operation for fistula in ano. Almost
all French surgeons maintain that a strong tent should constantly be kept in
the rectum, or that, at least, there should always be a fasciculus between the
lips of the wound. Without this, say they, cicatrization may commence first
OPERATIVE SURGERY. 909
towards the mucous membrane and thus the fistula be re-produced. The cure
can only be solid and certain, when it proceeds from the bottom towards the
edges of the incision. A patient who was going on very well was for a short
time abandoned by Sabatier, who perceived by the end of three weeks that
the fistula had formed again, and that the assistant to whom he had confided
him, had not used the tent judiciously. The incision was recommenced.
Every dressing was performed with the greatest care by Sabatier himself, and
this time the disease completely disappeared. M. Boyer makes use of abso-
lutely the same language, and states facts precisely parallel. Ponteau, who
has povverfully opposed this doctrine, however, asserts as warranted also by
experience, that the tent is not only useless but injurious, owing to the irri-
tation and compression which it exercises upon the bleeding surface ; which,
according to him, requires no other treatment than that of a simple wound
which is left to suppurate. The principles of Ponteau are universally adopted
in England. A strip of fringed linen or a few pledgets of lint is all that it is
thought proper to place between the edges of the fistula; and Mr. Samuel
Cooper, among others, does not understand what he calls the French routine.
Upon this point, as upon so many others, I think it easy to come to a right
understanding. It is not probable that practice offers as much difference on
the question as books do. The object is to prevent the union of the lips of
the wound before the action in the fundus has been altered, to compel it to
cicatrize gradually from its sides towards its deepest points. Now to ac-
complish this what is required ? The fringed linen will not always answer,
for it will be most frequently thrown by the wound into the anus itself.
Neither is the large cylinder of thread which is in use among us indispensable,
for we can with a tent much smaller and more flexible, keep the solution of
continuity sufficiently apart. It has, moreover, the serious inconvenience,
when its use is too long continued, of flattening the cellular granulations,
the development of which it likewise impedes. Reasoning and experience
concur in the assertisn, that a tent of moderate size is advantageous during
the first ten or twelve days; that afterwards it may without injury be gra-
dually diminished in size ; and that as soon as the surface of the wound seems
red and disposed to cicatrize it is useful to dress it flat with soft lint. In all
other respects this wound is to be treated like any other, and also the different
symptoms, local, or general, which may occur during the course of recovery.
Art, 7. — Cancers,
No part is more liable to lardaceous and even cancerous degeneration, than
the end of the rectum. This disease sometimes presents itself under the
form of tumors more or less prominent, and of greater or less sized bases ;
sometimes appearing like a perforated diaphragm, particularly when the
valve described by Mr. Houston is the seat of the affection ; sometimes like
flat surfaces, more or less extended in height, thickness, or in width which
occasionally occupy the entire circumference of the organ. When topical
applications, divisions of the frena and compression have proved insuffi-
cient, and the disease progresses in spite of theiruse, it will, it is to be feared,
whether cancerous or not, end fatally if some more effectual remedy is not
opposed to it.
910 NEW ELEMENTS OF
Extirpation is a last refuge to which the mind then naturally reverts. The
idea occurred to several persons, who all shrunk before the danger and diffi-
culty of applying it to practice. Desault thought it should be proposed for
such tumors only as were of a bad character, very limited in extent, movable,
and the difterent ramifications of which it was easy to reach. M. Boyer is
of a similar opinion. The whole of this school of the old Academy of Sur-
gery had coincided in this sentiment, which is tliat of Morgagni originally,
when some years ago M. Lisfranc undertook to establish the contrary opinion.
The cancerous anus can, according to him, be extirpated entire like the breast,
testis, or any other organ of the body. The surgeon who undertook it
during the time of Morgagni, could not, it is true, accomplish it ; and Be-
clard, who, according to M. Paris, used in his course of lectures upon Opera-
tive Surgery, at La Pitie in 1822 and 1823, maintained that in the present
state of surgery, scirrhous induration of the rectum need not prove necessa-
rily fatal, as the parts diseased should be removed, taking every precaution
warranted by the nearness of the bladder, and by the numerous vesse>s
which surround the lower end of the rectum, had never any opportunity of
performing it. Paget would appear to have first done it with success, on the
9th June, 1739, in the presence of Boudon and his brother. He excised
about an inch and a half from the circumference of the rectum. What
surprised him most, was to see defecation go on in the new anus, as it had
done before the operation, although nearly all the sphincter, or the plane of
circular fibres which surround the anal opening, had been amputated. After
an attempt to explain the formation of a new constrictor muscle, and to
account for the mechanism by which M. Gele was enabled to retain both solid
and liquid fecal matters, and even wind, Paget draws the conclusion that
extirpation of the anus, to even a considerable height is practicable. It fell
to the lot of M. Lisfranc to put this opinion to the test. His first patient
upon whom he operated, Pebruary 13th, 1826, was perfectly well on the ISth
of April following. He obtained a like success in the month of January,
1828, in the case of a woman, and a third in another woman, operated on the
15th July and cured October 28th of the same year. In a fourth patient the
cure remained doubtful. A fifth died on the 10th March, 1829, four days
after the operation of pelvic suppuration, and probably of phlebites. A sixth,
a man aged seventy -two years, died on the following day, the autopsia of which
it was not practicable to make. His seventh patient died at the end of
twenty-five days, also having pus in the pelvis and veins. The thesis of M.
Pinault, which contains all these facts, contains also two other cases of
recovery, whence it follows that in the month of August, 1829, that M. Lis-
franc had performed nine of this kind, five recovery, one partial success, and^
three deaths. I do not, therefore, see why we need hesitate to follow his ex-
ample, whenever a necessity occurs for so doing.
Tlie method of Operation. — The patient prepared, situated and held as if
for a fistula, except that instead of one thigh only, both should be separated
by a pillow and fixed at a right angle oh the trunk, whilst an aid draws the
buttock asunder, and makes tense the skin ; the surgeon, by means of two
demi-lunar incisions which come together at the coccyx and at the perineum
to form an ellipsis, encircles the disease below; dissects the ellipsis upon its
outer face from below upwards, first to the right and then to the left ; detaches
OPERATIVE SURGERY. 91 1
it gradually fronx the neighboring tissues, being careful to leave nothing of
diseased character without ; stops when lie comes to the sphincter ; intro-
duces the left index finger into the anus ; uses it as a hook to depress the
scirrhous ring, which he tries to bring outwards, whilst at the same time the
assistant pulls upon the dissected ellipsis ; takes the bistoury in his right hand,
continues to incise circularly the adhesions of this portion to the surrounding
parts, to be beyond the extent of the disease if possible, and concludes by
detaching the whole mass by large incisions with scissors curved on their
flat side, or else with the bistoury which he has used all along.
When the cancer is deeper and more adherent, or comprises a greater
thickness of tissues, M. Lisfranc begins with good scissors to divide the
angle or posterior wall of the dissected ellipsis vertically, and extends this
incision high enough up into the rectum. His assistants then pull with strong
hooks or forceps upon the rest of the circle, whilst the operator extends the
division as far as possible upwards with the bistoury, guided by the finger in
the anus, and by the thumb applied on the outer surface of the flap. When
he has proceeded beyond the limits of the disease, tlie curved scissors may
be taken instead of the bistoury, in order to separate the dissected mass, cir-
cularly from the portion of rectum which is to remain. Its extremity is
carried into the coccygean fissure, so as successively to embrace either half,
and to cut them from behind forwards, being careful to do so upon healthy
tissues only, and use double caution as we near the genito-urinary organs.
In operating on a female, a well informed assistant is to keep one or two
fingers in the vagina, and to watch the motions of the knife or scissors in that
direction, whilst the surgeon is dissecting away the cancer forwards, or is
attempting to do, at great depth. In the male, the urethra, bladder and prostate
render this stage in the operation one of still greater delicacy. A large
catheter in the natural passages, is doubtless an invaluable guide, which
would be but a trifling support, however, had the surgeon not *' in his minds
eye" all the requisite degree of knowledge as to the anatomy of the perin-
eum, or if he were not accustomed to the use of a knife. When the opera-
tion is over, the operator passes his finger over every point in the wound, and
if he detects any tubercles, portions or parcels of diseased tissue which have
escaped him, seizes them directly with a hook or forceps, and with a bistoury
or scissors at once incises them, whether internal or upon the skin. The
divided arteries belong to the same branches which are met with in the ope-
ration for fistula in ano ; to which, in some cases, must be added the trans-
versa, and superficialis perinei. All those which are noticed as they are cut,
are to be tied, otherwise there would be much risk of not finding them after-
wards, because being stretched and elongated at the time they are cut, they
ascend very high into the pelvis, and if we endeavor to draw them out by pull-
ing upon the end of the rectum, the compression they undergo prevents their
springing. Still, they are very seldom large enough to cause any serious hem-
orrhage. If, however, it occurs, refrigerants, styptics, and ))alls of lint,
methodically applied, tamponing, and in short all the means detailed in former
articles, must be opposed to its progress. If during the operation so much
blood flows as to interfere with the operator, we may, as M. Lisfranc is made
to say by M. Pinault, wait a (ew moments, and arrest it by lint steeped in cold
water, unless ligature or torson can be applied.
912 NEW ELEMENTS OF
The tent is of more importance after this operation than after all others.
It must be large and long. The finger must precede it; bear it strongly
backwards to find the new aperture of the rectum, and afterwards tilt
it, in an opposite direction to cause it to penetrate easily into it. A soaked
rag, spread with cerate, is applied upon the bleeding surface, receives its
extremity, to which is added some raw lint, compresses, and the double T
bandage. By neglecting to use the tent in the beginning, and merely spread-
ing a perforated linen rag to receive the lint over the wound, as M. Lisfranc
did; and only recurring to the use of tents about the tenth to the fifteenth
day, the first dressing is perhaps rendered more quick and rather more easy,
but to me it seems to create difficulties for the future; and that it would be
more reasonable to do as I have before described.
For a few days the patient is flooded with a discharge of grey, or blackish
pus, mixed with feces ; the wound then deterges gradually, and from the
fifteenth to the twentieth day begins to contract. The skin is, as it were, drawn
towards the pelvis, and the orifice of the intestine becoming adherent to the
parts around, approaches the surface at the same time, so that at the end of
the cure there remains only a loss of annular substance of about an inch in
height, or even less ; the preserved fibres of the levator ani, of the aponeuro-
sis, of the termination of the rectum, and other tissues blended into one ring,
reproduce to a certain point the sphincter muscle, supposing it to have been
removed, and thus, after the cure there is much less disfigurement than might
have been at first supposed.
For this cure to be certain, and to be followed by no relapse, the use of
dilators must not suddenly be abandoned. The new anus has so great a
tendency to cohere, that if the tents were not to be persevered in for at least
some weeks after the healing of the wound, and returned to, from time to
time, for several months, most patients would, ere long, be affected with a con-
traction here, by which the fruits of all their sufferings and the benefits of an
admirably constituted operation would be wholly lost. From this we see
that cancer of the rectum may be subjected, like that occurring in the breast,
to the chances of removal, whenever it may appear practicable to remove the
whole disease, without too much havoc in the parts ; that is to say when it
may be easily passed with the finger, when it is confined to the parietes of
the intestine, and has not yet gone beyond the line of demarcation between
the constituent parts of the ischio- rectal excavations.
In other cases, and whenever its adhesions with the vagina, bladder, pros-
tate, or urethra are too close to be easily destroyed, it must be renounced
here, as under the same circumstances, would be done any where else.
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